Introduction
Neuroactive steroids can trigger biological functions in human hypothalamus in health and disease for instance by affecting specific stress-related neuropeptide/neurotransmitter systems. Recent studies have shown a biphasic and dynamic relationship between fluctuating progesterone levels and the risk of suicide [
1,
4,
43]. Both clinical and forensic studies reported that suicidal behaviors in fertile women are more prevalent during the peri-menstrual period when peripheral progesterone levels are high [
4,
43], and in menopausal and amenorrheic women when peripheral progesterone levels diminish [
1]. Moreover, a nationwide prospective analysis has reported that, among contraception users, the suicide risks increase with a larger proportion of progesterone in the contraceptive [
52]. In addition, higher plasma progesterone, but not estrogen levels, were found in women who had attempted suicide repeatedly [
40]. Until now, however, studies on progesterone effects on the human central nervous system in relation to suicidal behaviors, were lacking [
21]. In humans, progesterone regulates neural responses through the progesterone receptor (PR) [
9]. A structural MRI study reported that oral contraceptive use is associated with smaller hypothalamic volumes in healthy women [
12]. We therefore mapped the distribution of PR in the human hypothalamus with respect to age and sex and investigated its neurobiological signatures in glia and peptidergic neurons. Subsequently, we studied the possible relationship between changes in PR-expressing peptidergic neurons and suicide, focusing on a key stress-regulatory and PR-dense area in the hypothalamus, the infundibular nucleus (INF; in rodents homologous to the arcuate nucleus, ARC) [
54].
The INF contains two distinct populations of neurons, the pro-opiomelanocortin (POMC)-expressing neurons and the neuropeptide Y (NPY)-expressing neurons, that are both involved in mood disorders (MD) and suicide. Preclinical stress studies have revealed that POMC
+ neurons in the ARC are involved in the regulation of depressive-like behavior [
46]. A combination of selective serotonin reuptake inhibitors (SSRIs) and serotonin receptor 2 A (5-HT2A) receptor antagonists has been shown to enhance therapeutic responses in a number of psychiatric disorders, while the 5-HT2A receptor is localized on ARC POMC
+ neurons [
36,
37]. Clinical studies have shown selective epigenetic alterations on the POMC gene of adolescents who suffer from depression and self-injuries [
64]. Adults with major depressive disorder (MDD) have higher plasma levels of POMC, and their responses to antidepressants depend on the presence of certain POMC haplotypes [
11,
29]. Moreover, naltrexone, a competitive antagonist of opioid receptors that can cause a strong increase in POMC activity in the INF, attenuates the anti-suicidality effects of ketamine [
6,
62]. In postmortem observations, higher pituitary POMC expression has been found in brains of suicide completers compared to controls [
30]. Thus, excessive POMC activity in the INF and pituitary seems to be related to suicidality. Contrary to POMC, rodent models of depression reported lower levels of NPY in plasma, cerebral spinal fluid, frontal-limbic regions, and ARC [
15,
22,
39]. Interestingly, in these compartments, NPY levels were normalized by both, SSRIs and electroconvulsive therapy [
13,
24]. Together, these preclinical observations point to marked antidepressant effects of NPY, with prominent involvement in the ARC. In humans, declining NPY expression levels in the periphery and the central limbic system were also reported in MD [
27,
42,
61]. Intranasal NPY administration to patients with MDD elicits rapid antidepressant effects [
38]. So far, however, the alterations in both the POMC and NPY systems in the human hypothalamus, in relation to MD and suicide, remain poorly understood.
Based on the information discussed above, we hypothesized that progesterone may play an important role in MD and suicide by affecting the activity of stress-related neurons that co-express PR and innervate their postsynaptic partners. In this study, we first investigated the distribution of PR in the human hypothalamus. In addition, we characterized PR co-expression in cell types across hypothalamic nuclei. To investigate whether PR was specially associated with MD, death ideation or suicidal behaviors, we further quantified the total numbers of POMC+, NPY+ neurons and their co-localization with PR in the INF in 28 individuals with MD and in 17 well-matched controls.
Discussion
Human hypothalamus plays a major role in mood and stress modulation, but the hypothalamic pathophysiologic systems that differentiate suicidality from MD are poorly understood and continue to be debated. Here, we show for the first time, strong PR-associated changes in a specific group of peptidergic neurons in relation to suicide. Our major findings are: (1) hypothalamic PR-containing cells are concentrated in the nuclei adjacent to the third ventricle in a relatively stable pattern in both sexes throughout the lifespan, (2) various peptidergic neurons as well as neural progenitors co-express PR, (3) POMC+ neurons in the INF are increased in suicide completers with MD, and this elevation is primarily due to PR/POMC co-expressing neurons, (4) NPY+ neuron number in the INF is sharply reduced in patients with MD, but PR/NPY co-expressing neurons do not participate in this decrease. We also report a sex difference of a reduced NPY expression in males but not females, when comparing MD cases versus controls. Together, these findings add to the growing evidence supporting the involvement of endogenous opioid system in suicide and suggest that progesterone-mediated, hypothalamic peptide alterations are an important molecular basis of psychopathology in suicide.
Local PR expression in human hypothalamus has been reported [
26,
32]. In this study, we show the distribution of PR
+ cells throughout lifespan in the human hypothalamus, which is generally in accordance with animal studies [
59]. Here, PR was present in specific hypothalamic nuclei known to have diverse hormone-mediating and neurodevelopmental functions in, e.g. the anxiety and stress response, neurogenesis, sexually dimorphic behaviors, circadian rhythm, feeding and metabolism, drinking, parental behavior and sleep [
55]. This widespread distribution suggests that progesterone via hypothalamic PR may affect a multitude of neuroendocrine regulators. The largely identical distribution pattern over the ages between sexes thereby seems to be independent of the progesterone plasma levels. Central progesterone could be derived from progesterone entering the brain after being synthesized in the periphery as a sex hormone, or it could be locally produced by astrocytes as a brain-derived neuroactive steroid [
49]. Of note, the density of PR
+ cells along the third ventricle decreased from the ventromedial to the dorsolateral hypothalamus, indicating that the INF, a nucleus that is anatomically located outside the blood-brain barrier, might be a major structure through which peripheral progesterone enters the brain. Positive PR expression in the epithelial cytoplasm, but not in the nuclei of CP, supports this possibility, which is also in accordance with the idea that both peripherally synthesized and neuroactive progesterone inputs may regulate emotional and metabolic integration [
34].
The presence of PR in neural progenitors and specific populations of peptidergic neurons potentially determines the neurobiological substrate that is modulated by progesterone in the human hypothalamus. Selective co-expression between PR and neuropeptides, such as CRH, SOM and TH, in different human hypothalamic nuclei indicates that progesterone regulation of the neuroendocrine system has region- and function-heterogeneous targets. We found PR to be present from early in the second trimester of pregnancy until old age. PR further presented co-localization with neural progenitors in the SVZ, which is the main neurogenic niche in the adult human brain [
58], indicating that progesterone activity may be involved in human adult neurogenesis [
10]. Supporting this possibility, we reported here binuclear POMC
+ and SOM
+ neurons that may correspond to the late phase of mitosis and post-mitotic maturation of neurogenesis in the INF.
Studies have demonstrated that endogenous opioids play important roles in modulating stress-related behaviors [
2,
41]. Although POMC
+ neurons in the INF are well known to be involved in eating behavior, the elevated POMC expression we describe here, indicates the involvement of the endogenous opioid system activation in suicide [
62]. Progesterone is increased following stress [
28]. In ovariectomized monkeys, it has been shown that progesterone administration causes the release of hypothalamic β-endorphin, a major derivative of POMC, into peripheral blood [
60]. Evidence has shown that the plasma level of β-endorphin was increased in suicide attempters, while this increase positively correlated with lifetime suicide attempts [
7,
20,
25]. One may assume that in individuals experiencing suicidality, progesterone may modulate POMC synthesis, leading to opioid activation and subsequent suicidal behaviors [
33,
63]. Among subjects with MD, the numbers of POMC
+ and PR/POMC
+ neurons both increased in suicide, and the proportion of PR/POMC
+ neurons increased both in MDS and MDE. This indicates that progesterone is associated with suicide ideations, but the final and fatal suicidal behaviors, which are absent in patients with legal euthanasia, may have different molecular bases. In addition, an animal study reported that progesterone administration can elicit long term POMC elevations [
44], in spite of the fact that the elimination half-life of progesterone by oral intake was approximately 5 h [
45]. This may provide a possible explanation for the observation that women have a high tendency of suicide during menstrual and postpartum periods when their peripheral progesterone levels drop sharply [
1,
4,
43]. Moreover, PR expression has been found to be stronger in both sexes during adolescence than during childhood, and may correspond to an increased suicide rate in adolescents [
47].
In this study, the expression of NPY in the INF of depression cohorts was sharply reduced, agreeing with a previous report that showed decreased expression of NPY in the prefrontal cortex and hippocampus of depressed suicides [
50]. Our earlier research showed that the duration of an agonal state before death is accompanied by a decreased NPY expression [
16]. For this reason, we studied brain donors who underwent legal euthanasia as they have very short agonal states. By comparing NPY
+ neurons in CE versus MDE and CN, we found that a reduction in numbers was present only in MD. Our data agreed with an antidepressant effect of NPY, and we concluded that MD, rather than death ideations, could play a major role in impairing hypothalamic NPY reserves. It is not known whether the increase of NPY in the plasma of suicide completers is caused by the NPY released from other regions of the brain or from other organs [
31]. Given that there is a small proportion of PR/NPY
+ neurons that showed no changes in the different conditions, we have no evidence to connect their association with MD or suicidality.
Neurons in the INF control behaviors by synaptic regulations across various neural circuits. We investigated a first and important step in this network, i.e., the relationship between the INF and PVN. The observations that POMC
+, NPY
+, CRH
+ and TRH
+ neurons terminate on each other provide a morphological substrate for their reciprocal interaction. Terminals of POMC
+ neuron axon projections, including the other hypothalamic nuclei, thalamus, amygdala and brainstem, could be the targeted regions that respond to adverse stimuli. Among them, the ventral tegmental area and thalamus have been associated with the opioid system in depression [
33,
46]. Tracing the INF projections of this opioid population may help to identify brain areas interconnected to the neuropathology of death ideation and suicidal behaviors.
It is important to note that only MD males, but not MD females have fewer NPY
+ neurons in the INF. To the best of our knowledge, studies that showed hypothalamic NPY reductions in depression models and normalization of depressive-like behaviors after treatments used only male animals [
15,
23,
24]. Previous research showed that NPY expression in the INF is activated by testosterone only in male animals [
57] and testosterone deficiency is accompanied by a higher incidence of depression, especially in males after midlife [
51]. This may relate to the less robust reductions in NPY
+ neurons in females. As the subjects in this study have a median age over 60, decreases in testosterone possibly underlie the observed NPY reduction.
There are a few aspects of our study that require consideration. Menstrual information was not recorded in primary clinical data. Since the number of younger women is small, this will likely not influence our general conclusions. Secondly, the sample size is relatively small, limited by the unique cases of legal euthanasia and the inclusion and exclusion criteria we used. Another limitation is that we could not stratify the manner in which every subject accomplished suicide. For instance, information about violent or non-violent categories was not available in the clinical data. It prevented us from analyzing whether the suicide manner is confounding the progesterone-associated activation of the opioid system. In addition, our study employed human postmortem brain tissue which makes it inevitable to consider the possible role of antidepressants. Therefore, we distributed the antidepressant users, in relation to the pharmacologic effects in MD, equally among the subsets.
In conclusion, we systematically examined the anatomical and functional organization of PR in the human hypothalamus and indicated its association with suicide by demonstrating increased numbers of PR/POMC+ neurons in the INF in patients with MD and suicidality. Moreover, the identification of distinct neuronal subpopulations involved in the effects of progesterone on suicidality will help better understand the molecular mechanisms underlying MD and suicide. We suggest that special attention should be paid to females with MD, who use hormonal contraception containing a high concentration of progesterone.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.