Sports Med
DOI 10.1007/s40279-013-0081-6
REVIEW ARTICLE
How Sex Hormones Promote Skeletal Muscle Regeneration
Martina Velders • Patrick Diel
! Springer International Publishing Switzerland 2013
Abstract Skeletal muscle regeneration efficiency
declines with age for both men and women. This decline
impacts on functional capabilities in the elderly and limits
their ability to engage in regular physical activity and to
maintain independence. Aging is associated with a decline
in sex hormone production. Therefore, elucidating the
effects of sex hormone substitution on skeletal muscle
homeostasis and regeneration after injury or disuse is
highly relevant for the aging population, where sarcopenia
affects more than 30 % of individuals over 60 years of age.
While the anabolic effects of androgens are well known,
the effects of estrogens on skeletal muscle anabolism have
only been uncovered in recent times. Hence, the purpose of
this review is to provide a mechanistic insight into the
regulation of skeletal muscle regenerative processes by
both androgens and estrogens. Animal studies using
estrogen receptor (ER) antagonists and receptor subtype
selective agonists have revealed that estrogens act through
both genomic and non-genomic pathways to reduce leu-
kocyte invasion and increase satellite cell numbers in
regenerating skeletal muscle tissue. Although animal
studies have been more conclusive than human studies in
establishing a role for sex hormones in the attenuation of
muscle damage, data from a number of recent well
M. Velders (&)
Division of Sports Medicine, Department of Internal Medicine,
University Hospital Ulm, Leimgrubenweg 12-14,
89075 Ulm, Germany
e-mail: martina.velders@gmail.com; martina.velders@uniklinik-
ulm.de
P. Diel
Department of Molecular and Cellular Sports Medicine,
Institute of Sports Medicine, German Sports University,
Cologne, Germany
controlled human studies is presented to support the notion
that hormonal therapies and exercise induce added positive
effects on functional measures and lean tissue mass. Based
on the fact that aging human skeletal muscle retains the
ability to adapt to exercise with enhanced satellite cell
activation, combining sex hormone therapies with exercise
may induce additive effects on satellite cell accretion.
There is evidence to suggest that there is a ‘window of
opportunity’ after the onset of a hypogonadal state such as
menopause, to initiate a hormonal therapy in order to
achieve maximal benefits for skeletal muscle health. Novel
receptor subtype selective ligands and selective estrogen
and androgen receptor modulators (SERMs, SARMs)
promise to reduce health risks associated with classical
hormonal therapies, whilst maintaining the positive effects
on muscle repair. Dietary supplements containing com-
pounds with structural similarity to estrogens (phytoestro-
gens) are increasingly used as alternatives to classical
hormone-replacement therapies (HRT), but the effects on
skeletal muscle are currently largely unknown. Research
has started to investigate the combined effects of exercise
and alternative HRTs, such as soy isoflavones, on skeletal
muscle regenerative processes to provide safer and more
efficient therapies to promote muscle regeneration and
maintenance of muscle mass and strength in the aging
population.
1 Introduction
Efficient skeletal muscle regeneration is an important
aspect for the aging population, where declining muscle
mass and strength impacts on the ability of older people to
engage in regular physical activity and increases the inci-
dence of frailty-related falls. The blunted satellite cell

response in skeletal muscle of old versus young men fol-
lowing eccentric exercise is evidence for a regeneration
deficit of aging muscle [1]. Early skeletal muscle cross-age
transplantation experiments have revealed that muscle
regeneration is superior when an old muscle is transplanted
into a young organism compared with vice versa [2]. This
research first implicated a role for circulating factors
associated with the host environment in regenerative pro-
cesses. A large body of literature, mainly from rodent
studies, now provides strong evidence for the ability of
androgenic and estrogenic sex hormones to augment
satellite cell activation and to modulate inflammatory
dynamics during muscle regeneration [3–7]. Sarcopenia is
a major health issue, affecting 30 % of individuals over
60 years of age, leading to falls and physical disability.
However, aging skeletal muscle of both men and women
has been shown to retain the ability to respond to exercise
with increased satellite cell numbers [8]. Since estrogens
have been shown to increase satellite cell numbers [5],
combining exercise with pharmacological hormone thera-
pies seems a promising treatment strategy to increase
muscle mass and improve regeneration in elderly people.
Elucidating the molecular targets activated by the combi-
natory influence of both exercise and sex hormones in
skeletal muscle is essential in order to design effective
strategies to counteract sarcopenia and improve muscle
regeneration. This review therefore focuses on the molec-
ular mechanisms activated by sex hormones in response to
skeletal muscle injury due to unaccustomed exercise or
trauma.
In this article we review the literature incorporating arti-
cles from a PubMed search with the keywords ‘androgens’,
‘estrogens’, ‘phytoestrogens’, ‘estrogen receptor subtype
selective agonists’, ‘SERMS’, ‘SARMS’, ‘skeletal muscle’,
‘injury’, ‘regeneration’, ‘satellite cells’ and ‘inflammation’.
Relevant papers were selected for review, including a few
classical papers on estrogenic and androgenic actions in
skeletal muscle. The PubMed search revealed that there are
more ‘early’ (prior to 1965) articles on the effects of
androgens on skeletal muscle than there are articles on
estrogens and skeletal muscle. However, the number of
articles on both androgenic and estrogenic effects on skeletal
muscle increased sharply in the 1990s, and publication
numbers continue to be high to date. In 2012, a total of 188
papers were published on the effects of androgens in skeletal
muscle and 125 articles on estrogens and skeletal muscle.
The high publication numbers reflect the health relevance of
sex hormones and their role in skeletal muscle regeneration.
We begin this article with a brief general introduction of
skeletal muscle regeneration and an overview of the cel-
lular mechanisms of estrogenic and androgenic steroids in
skeletal muscle. We assess the latest evidence relating to
the effects of estrogens and androgens on skeletal muscle
M. Velders, P. Diel
regeneration in rodent injury, disuse or exercise models.
There is considerably less evidence available on the effects
of hormonal status on human skeletal muscle regeneration,
but existing literature is reviewed and compared with
findings from animal studies. In the last part of this review,
we examine data on the effects of estrogens and androgens
as therapeutic agents and discuss how this relates to exer-
cise training in the elderly population.
1.1 Skeletal Muscle Regeneration: An Overview
Although skeletal muscle is a post-mitotic tissue, it pos-
sesses a remarkable capacity for regeneration after injury
or disuse. This is evidenced by results from a rodent study
showing that a whole muscle can be removed, minced and
replaced, with morphological characteristics being restored
within 30–40 days [9]. The skeletal muscle repair process
can be categorized into three parts: (i) necrosis, (ii)
phagocytosis and repair, and (iii) remodelling and resto-
ration of muscle function [10]. The initial event after
muscle injury is necrosis due to membrane disruption and
activation of calcium-dependent proteases [11]. This is
followed by an invasion of myeloid immune cells into the
injured skeletal muscle areas. Myeloid cells numbers can
exceed 100,000 cells/mm3 in injured postnatal muscle [12].
Neutrophils are the first immune cells to be recruited to the
site of injury 1–6 h after muscle damage, followed by
macrophages (*48 h post-injury). Two distinct macro-
phage populations sequentially invade the injured muscle,
and their transition is important for the regeneration pro-
cess [13, 14]. Phagocytic M1 macrophages secrete pro-
inflammatory cytokines and promote phagocytosis of
necrotic cell material and satellite cell proliferation,
whereas the non-phagocytic M2 macrophage population
produces anti-inflammatory cytokines, which are vital for
myoblast differentiation and regeneration [13]. Recent data
from Saclier and colleagues confirm that differentially
activated, polarized macrophages control myogenic pre-
cursor fate. In-vitro co-culture experiments of myogenic
precursor cells with M1 or M2 macrophages show that M1
macrophages decrease cell fusion, whereas M2 macro-
phages stimulate myotube formation [15]. The authors also
show human data from an eccentric exercise study,
although with a small sample size, to support the concept
that macrophage polarization controls myogenic cell
activity. Proliferating myogenin-negative myoblasts were
detected in regenerating areas containing M1 macrophages
expressing pro-inflammatory markers, whereas myogenin-
positive differentiating myogenic precursors were associ-
ated with anti-inflammatory M2 macrophages [15]. The
importance of chemotactic factors, attracting myogenic
precursor cells and macrophages to the injury site is
revealed in macrophage chemoattractant protein (MCP)-1
Sex Hormones and Skeletal Muscle Regeneration
knockout mice, where regeneration is drastically reduced
[16]. A number of recent in vivo studies delineate some of
the mechanisms behind macrophage-mediated muscle
regeneration. In an immunodeficient mouse model, co-
injection of pro-inflammatory macrophages and human
myoblasts increased myoblast proliferation and cell
migration by switching to an anti-inflammatory phenotype
[17]. Macrophage injection also significantly improves
myoblast survival, adhesion and migration in dystrophic
mdx mouse muscle [18].
There is a tight link between the inflammatory response
and activation of myogenic precursor cells, including
Pax7? satellite cells. Non-steroidal anti-inflammatory drug
(NSAID) treatment significantly blunts satellite cell acti-
vation after unaccustomed eccentric exercise [19] or after
accustomed endurance exercise [20]. There is evidence that
non-muscle derived cell populations, originating from bone
marrow [21] or blood vessels, such as pericytes [18, 22],
have the ability to migrate into regenerating skeletal
muscle areas and participate in the regeneration process.
However, genetic ablation studies have convincingly
shown that other precursor cells do not compensate suffi-
ciently for the loss of satellite cells and that muscle
regeneration is severely compromised in satellite cell
depleted muscle [23–25]. Although satellite cells only
account for approximately 2–5 % of total muscle nuclei,
fewer than 10 satellite cells are capable of generating over
100 new muscle fibres [26]. Satellite cells have the stem
cell inherent ability to remain in a quiescent state between
the sarcolemma and basal lamina. Maintenance of the
quiescent state was recently shown to be regulated by
microRNA-489, which post-transcriptionally suppresses an
oncogene product involved in the proliferative expansion
of satellite cells [27]. Satellite cells are activated in
response to a myotrauma and begin to proliferate with a
doubling time of approximately 17 h in the mouse [28].
Satellite cells proliferate for 2–3 days and then withdraw
from the cell cycle to differentiate or return to quiescence
(asymmetric division). Differentiating satellite cells are
Pax7, MyoD and Myf5 positive, whereas satellite cells
returning to quiescence are only Pax7 positive [18].
Regenerating fibres can be detected by central nucleation, a
sign for satellite cells fusing with existing fibres or aligning
to form new myofibres to contribute with their DNA to
muscle growth and regeneration. Depending on the type
and severity of the injury, muscle regeneration can be
complete within 7–21 days post-injury [29].
1.2 Cellular Mechanisms of Estrogenic
and Androgenic Hormones
Estrogens, progestins and androgens are sex steroids pro-
duced by the reproductive organs and ‘non-classical’
tissues, such as adipose tissue. Sex steroid hormone targets
include the reproductive organs, bone, the vascular,
immune and nervous system, skeletal muscle and a number
of other organ systems [30].
Sex steroid hormones can act genomically through ste-
roid receptors with distinct functional domains, including
transcriptional activation domains (AF-1, AF-2), a DNA-
binding domain and a ligand-binding domain. A great
number of steroid receptor co-activators have been identi-
fied, which are recruited into the agonist-bound receptor
complex to make DNA accessible and allow the tran-
scriptional process to proceed [31]. In contrast, antagonist-
bound steroid receptors recruit co-repressors into the
receptor complex, which repress transcriptional activation
through activation of histone deacetylases [32]. Over
30,000 androgen receptor (AR) gene targets have been
identified in myoblasts in response to androgen treatment
using ChIP-on-chip technology, including a number of
genes involved in muscle growth and development as well
as micro RNA encoding genes [33]. Estrogen receptors
(ERs) bind to estrogen response elements on target genes
and modulate gene expression by interacting with tran-
scription factors and other co-regulatory factors upon
ligand binding. Two ERs are known to date (ERa, ERb),
with similar amino acid sequences but different tissue
expression levels. It has been shown that ERb reduces
ERa-regulated gene transcription in bone [34]. Based on
these findings, the concept of a ‘Ying Yang’ relationship
between the two receptor isoforms was introduced [34].
There is evidence showing that heterodimerization occurs
not only between ERa and ERb but also between ERa and
AR, adding additional complexity to sex steroid hormone
signalling. Co-expression of ER and AR in the presence of
17b-estradiol (E2) dose-dependently decreases AR tran-
scriptional activity [35]. Both ERa and ERb are expressed
in skeletal muscle of mice [36, 37], rats [38, 39] and
humans [40–42].
In addition to the classical transcriptional pathway
mechanism (steroid hormones ? steroid recep-
tors ? hormone response element [HRE]-mediated gene
induction) estrogens and androgens are also able to induce
rapid (seconds to minutes), HRE-independent effects
through protein–protein interactions, or non-genomic/non-
transcriptional effects through intracellular kinase signal-
ling pathways, by impacting on membrane fluidity or by
signalling through plasma membrane-bound steroid
receptors or non-nuclear receptors [43, 44]. There are
several lines of evidence providing compelling evidence
for the existence of non-transcriptional estrogen and
androgen pathways. For example, pituitary cell prolactin
secretion is stimulated only 5 min after testosterone
administration [45]. Also, estrogen induces rapid vasodi-
lation in vascular walls [46] and neuronal excitability in the

nervous system [47]. A number of studies have provided
evidence for the existence of membrane-associated estro-
gen-binding sites, including the pioneering work of Pietras
and Szego [48], which identified ER cell membrane sub-
fractions in isolated endometrial cells. There is now gen-
eral agreement that ERs can localize to the cell membrane
and to membrane-associated structures such as caveolae
[49], but other non-steroid membrane-associated receptors
may also interact with estrogens to activate downstream
second messengers and protein kinases [50].
Non-transcriptional steroid hormone signalling mecha-
nisms can be studied using cells expressing mutated steroid
receptors, steroid receptor blockers, inhibitors of RNA or
protein synthesis or steroid hormones linked to cell-
impermeable molecules such as bovine serum albumin
[50]. Studies using the AR-negative L6 myoblast cell line
or bovine serum albumin-linked testosterone have provided
evidence for the existence of non-transcriptional androgen
pathways by showing that testosterone treatment stimulates
myoblast proliferation and differentiation via G-protein
coupled signalling pathways [51]. In isolated skeletal
muscle, G-protein inhibitors blocked the fast (\2 min),
transient increase in intracellular calcium in response to
testosterone treatment [52]. This non-transcriptional tes-
tosterone-induced mechanism in skeletal muscle may be
relevant for the transcriptional regulation of calcium-sen-
sitive transcription factors, such as nuclear factor of acti-
vated T-cells (NFAT) or genes containing calcium-
sensitive promoter regions (e.g. calcium response element
[CARE]) [53]. Additional evidence for AR independent
androgen actions comes from studies using AR blockers.
Dihydrotestosterone (DHT) treatment of isolated mouse
muscle fibres, in combination with AR blockers, but not in
the presence of epidermal growth factor (EGF) receptor
inhibitors, increases isometric force in fast muscle fibres by
activating the mitogen-activated protein kinase (MAPK)
pathway [54].
2 Sex Steroids Augment Skeletal Muscle Regeneration:
Animal Studies
2.1 Transcriptional and Non-Transcriptional Effects
of Estrogens During Muscle Regeneration
Findings from Amelink, Bär and colleagues in the late
1980s and 1990s first showed that serum activities of
muscle enzymes, such as creatine kinase (CK), were ele-
vated in male rats after muscle-damaging exercise com-
pared with gonad-intact female rats, while ovariectomized
(OVX) female rats showed CK elevations similar to those
of male rats [55–57]. These findings first suggested that
estrogens may play an important role in protecting skeletal
M. Velders, P. Diel
muscle membranes from exercise-induced muscle damage.
Since then it has been argued that CK is a poor marker of
muscle damage, due to high intra-individual variability as
well as the dynamic nature of CK release and clearance
[58]. However, when systemic effects are removed and
skeletal muscle is studied in isolation in vitro, studies have
shown that basal and contraction-induced CK release was
still greater in male and OVX female rats than in intact
female and estrogen-treated male rat muscle [59, 60].
Findings from our laboratory agree with other published
data from rodent studies [55, 56, 61] by showing that
elimination of ovarian hormone production by OVX or
selective knockout of the ERb isoform results in higher
serum CK activity levels after muscle injury than in intact
rats [3] Furthermore, treating OVX rats with the natural
estrogenic ligand E2 and other substances with affinity to
the ERs (ERa and ERb selective agonists and the phyto-
estrogen genistein) attenuated serum CK activity after
toxin-induced muscle damage [3].
These findings argue in favor of estrogen’s non-tran-
scriptional effects, acting as a strong antioxidant and
membrane stabilizer and protecting sarcolemmal integrity
[3, 62]. While there is still debate on the role of estrogens
in preventing primary, structural muscle damage, particu-
larly in human exercise studies, evidence is more conclu-
sive for the role of estrogens in preventing secondary
muscle damage by modulating inflammatory dynamics of
skeletal muscle after eccentric exercise [4, 61], notexin
injury [3], ischaemia/reperfusion injury [63] or recovery
after disuse [64, 65]. The inflammatory cascade initiated
after injury or unaccustomed muscle use involves an early
invasion of neutrophils followed by the infiltration of M1
and M2 macrophages, which secrete pro- and anti-inflam-
matory cytokines, respectively [14, 66, 67]. Neutrophil
invasion is exacerbated by OVX [64] and attenuated by
estrogen treatment [3, 5]. While neutrophils serve impor-
tant functions clearing tissue debris, they lack the ability to
differentiate between intact and damaged proteins [68]. A
study using an ER antagonist has shown that the attenu-
ating effects of estrogens on leukocyte infiltration is a non-
ER mediated process [4] and is most likely due to the
positive effects of estrogens on lipid membrane fluidity
[69]. Another published E2-mediated non-transcriptional
mechanism relates to the ability of E2 to reduce inflam-
matory gene expression in macrophages by inhibiting
nuclear factor kappa-light-chain-enhancer of activated B
cells (NF-jB) intracellular transport [70]. Decreased NF-
jB-mediated gene expression may partially explain our
findings of reduced gene expression levels of the pro-
inflammatory cytokine tumor necrosis factor (TNF)-a and
increased expression of the anti-inflammatory cytokine
interleukin (IL)-10 in skeletal muscle of estrogen-treated
OVX rats [3].
Sex Hormones and Skeletal Muscle Regeneration
While excessive skeletal muscle inflammation leads to
tissue injury by oxidative damage [71], a certain level of
inflammation is required to initiate the muscle-regeneration
process by clearing cellular debris and by stimulating
satellite cell function. Satellite cell activation, proliferation
and fusion with existing myofibres are vital processes
during skeletal muscle regeneration [23]. Studies using
OVX rats as a model of menopause have shown that
satellite cell activation is reduced after toxin injury [3] or
eccentric exercise [4, 5, 72], while estrogen substitution
leads to an augmented satellite cell response. The stimu-
lating effects of estrogens on satellite cell activity are also
evident when male rats are treated with E2 before eccentric
exercise [73]. The effects of E2 appear to be ER mediated
[4] and the absence of the ERb receptor isoform in
knockout mice particularly impacts negatively on markers
of satellite cell activation, such as Pax7 or MyoD [3].
While our data suggest that the ERb receptor isoform is the
predominant ER isoform inducing E2-mediated transcrip-
tional responses during muscle regeneration, another study
using an exercise-induced injury model has shown that the
ERa selective ligand propylpyrazole triol (PPT), similar to
E2, augmented satellite cell number and activation [74].
2.2 Androgens Promote the Skeletal Muscle
Regeneration Process
The effects of anabolic steroids on muscle anabolism and
regeneration were first studied using rodents in the 1960s
and 1970s [75, 76]. Testosterone supplementation of cas-
trated young and aged mice increases the number of pro-
liferating satellite cells and fibre cross-sectional area in
regenerating muscle [77]. Administration of nandrolone to
mice after toxin-induced muscle injury augments growth-
related gene expression, muscle weight and size of regen-
erating fibres [78]. The effects of nandrolone appear to be
particularly beneficial to a slow fibre-type muscle (e.g.
soleus) in terms of muscle mass and myosin heavy chain
expression [6]. However, fast fibre type muscles (extensor
digitorum longus [EDL]) also respond to nandrolone
treatment after toxin injury with an increased frequency of
large fibres and enhanced expression of MyoD [78]. While
nandrolone treatment before surgical ablation of the gas-
trocnemius and soleus muscles did not enhance compen-
satory hypertrophy of the plantaris muscle, steroid
treatment significantly reduced the mean size of the
necrotic area [79].
There appears to be a common mechanistic basis for the
effects of androgens and estrogens on muscle-regeneration
processes. Both steroid nuclear receptor classes promote
satellite cell activation and proliferation and stimulate
expression of growth-promoting genes [3, 5, 78, 80]. Less
is known about the effects of androgens compared with
estrogens on inflammatory dynamics during muscle
regeneration. However, there is limited evidence to suggest
that the effects of androgens on inflammatory cytokine
profiles are age dependent. Nandrolone treatment attenu-
ates overload-induced IL-1b expression only in old rodent
muscle and IL-6 in young and old muscle [81].
3 Effects of Hormonal Status on Muscle Damage,
Repair and Function: Human Studies
3.1 Effects of Estrogenic Status on Human Skeletal
Muscle Health
While animal studies have convincingly shown that estro-
gens ameliorate post-exercise muscle damage and inflam-
mation [4] and enhance skeletal muscle repair processes
[3–5], evidence from human studies is less abundant. An
excellent point/counterpoint discussion on the role of
estrogens and sex on post-exercise indices of muscle
damage, inflammation and repair has highlighted the fact
that there is a discrepancy between findings from animal
versus human studies relating to the effects of estrogens on
muscle damage, inflammation and repair [62, 82, 83]. This
may be largely because most studies have investigated sex
differences rather than studying human populations dis-
cordant for estrogen levels. There are a number of sex-
based differences other than estrogen status, which may
affect outcome measures. A more promising approach for
studying the specific role of estrogens on skeletal muscle in
humans, as suggested by Phillips in a point/counterpoint
discussion by Pizza et al. [83] is a comparison between
people of the same sex discordant for estrogen status, such
as women before and after surgical ovariectomy, HRT-
treated versus untreated post-menopausal women, or men
treated with high dosages of estrogen after a sex change. A
study comparing twins discordant for HRT use showed that
the twins using HRT exhibited significantly greater muscle
strength and mass than the twins not using HRT [84]. A
year-long HRT plus exercise intervention with post-men-
opausal women showed that exercise and HRT had addi-
tive positive effects on functional measures compared with
HRT alone [85]. More recent evidence suggests that
estrogen treatment is not only beneficial for skeletal muscle
homeostasis and regeneration in older women, but also
attenuates neutrophil infiltration after damaging eccentric
muscle contractions in young men [86].
Dieli-Conwright and colleagues [87–91] have provided
mechanistic evidence for the beneficial effects of HRT on
human skeletal muscle mass and function. They showed
that expression of genes promoting muscle growth (myo-
genic regulatory factors) was enhanced, while expression
of negative regulators of muscle growth, such as myostatin

or proteolytic factors, was reduced in skeletal muscle of
post-menopausal women using HRT compared with post-
menopausal women not using HRT [87, 88]. The reduction
of myostatin and activin IIb receptor expression was also
greater after acute eccentric exercise in women using HRT,
which may be one of the molecular mechanisms underlying
the effects of estrogens on muscle mass and strength
preservation [87]. Also, ER transcriptional activity, deter-
mined via messenger RNA (mRNA) expression of ER co-
regulators, was significantly greater following eccentric
exercise in skeletal muscle of women using HRT versus
post-menopausal women not using HRT [90]. The study is
the first to show that acute eccentric exercise enhances ER
transcriptional activity and that ER co-regulator gene
expression is further enhanced in postmenopausal women
using HRT. The downstream signalling pathways are
starting to be deciphered, and accumulating evidence
suggests that the positive effects of HRT on muscle mass
and function observed in human studies are due to estro-
gens creating a pro-anabolic skeletal muscle environment
[68, 92].
Evidence from rodent studies supports the claim that
there is an inverse relationship between protective effects
of HRT and the duration of hypoestrogenicity [93]. This
‘window of opportunity’ hypothesis is also supported by
human studies showing that cardiovascular benefits are
greatest and risks are minimized when HRT is initiated
before 60 years of age or within 10 years after the onset of
menopause [94]. Gene expression profiling of skeletal
muscle from early-stage post-menopausal women before
and 12 months after an intervention, consisting of a plyo-
metric power training and HRT, revealed significantly
enhanced gene expression related to mitochondria func-
tionality, carbohydrate metabolism and calcium signalling
[92]. More research is needed to determine the effects of
HRT initiation from the onset of menopause on skeletal
muscle health.
3.2 Androgen Levels in Humans Impact on Muscle
Mass and Strength
Andropause in men is associated with physical and emo-
tional changes caused by decreasing androgen levels. Cir-
culating testosterone levels decline 1–3 % per year starting
from the fourth decade of life [95]. Men are generally
considered hypogonadal when morning serum total tes-
tosterone falls below 300–500 ng/dL [96]. ARs in human
skeletal muscle mediate the effects of androgens on myo-
nuclear accretion and protein synthesis [51, 80, 97], and
several studies have shown that testosterone administration
improves muscle mass and strength in hypogonadal men
[96], but also in young eugonadal men [98] and in men
with HIV-induced muscle wasting [99]. Androgens have
M. Velders, P. Diel
the potential to promote skeletal muscle regenerative pro-
cesses based on their ability to promote protein synthesis
and satellite cell activation [6, 80, 100]. Supraphysiological
doses of testosterone have been shown to increase satellite
cell numbers, and this change was significantly correlated
with total and free testosterone concentrations [101]. In
addition, testosterone also modulates cellular protein deg-
radation and inflammatory processes by reducing the
expression of the ubiquitin ligase muscle atrophy F-box
(MAFbx) [102] and by stimulating the expression of anti-
inflammatory cytokines [103].
Although there is a clear sex difference in endogenous
testosterone, with levels in women being one order of
magnitude lower than in men, total serum testosterone
levels are significantly reduced in late post-menopausal
women, and estrogen therapies lead to further reductions in
testosterone levels [104]. The physiological significance of
reduced testosterone levels for muscle mass maintenance
or muscle regenerative capacity in response to estrogen
therapies requires further study. Although androgen thera-
pies in women remain highly controversial, older females
benefit from androgen treatment in terms of muscle protein
synthesis [105].
Circulating anabolic hormone levels such as testosterone
are significantly elevated in response to high volume,
moderate- to high-intensity exercise using large muscle
groups [106]. The hormonal response to strength training,
consisting of elevated free testosterone and insulin-like
growth factor IGF-1 levels at rest and during exercise, can
also be observed in older men, although at lower absolute
levels than in younger men [106]. Recent evidence sug-
gests that oral dehydroepiandrosterone (DHEA) supple-
mentation protects skeletal muscle of young men from
exercise-induced damage [107].
4 Sex Hormones: Therapy Implications
The importance of female sex hormones as major deter-
minants of movement drive and physical activity levels has
been clearly demonstrated in rodent studies showing that
(i) female rodents are generally more active than male
rodents [108, 109], (ii) gonadectomized male and female
rodents exhibit reduced levels of voluntary physical
activity [110], and (iii) treating gonadecomized male
rodents with testosterone or E2 and female rats with E2
significantly increases voluntary physical activity. While a
causative effect between sex hormones and physical
activity drive has yet to be shown in human studies [111],
the positive effects of both male and female sex hormones
on muscle mass and strength, as well as attenuation of
muscle damage after eccentric exercise are well docu-
mented [84, 112–114].
Sex Hormones and Skeletal Muscle Regeneration
4.1 Selective Estrogen and Androgen Receptor
Modulators as Therapeutic Agents
Selective estrogen and androgen receptor modulators
(SERMs and SARMs) exhibit tissue-selective estrogenic or
androgenic activity. They are developed to exploit the
beneficial effects of estrogens and androgens on various
target tissues such as skeletal muscle, bone and the vas-
cular system without the known estrogen-related adverse
effects on the breast and prostate.
Data from our laboratory have shown that the prohor-
mone 19-norandrostenedione possesses SARM-like prop-
erties by selectively stimulating skeletal muscle growth
without affecting prostate proliferation [115]. Similar
results were obtained by Gao and colleagues, showing that
the SARM S-4 induces strong anabolic effects in skeletal
muscle, bone and the pituitary gland of orchiectomized
rats without causing adverse effects on the prostate
compared with DHT [116]. In addition to counteracting
castration-induced skeletal muscle atrophy, SARMs have
also been reported to attenuate glucocorticoid-induced
atrophy by reducing the expression of ubiquitin ligases
and by inhibiting dephosphorylation of factors involved in
protein synthesis [117]. A number of SARMs are cur-
rently being tested in clinical trials as function-promoting
therapies, including GTx-024 (enobosarm), where treat-
ment dose-dependently increases lean body mass and
physical function in elderly men and post-menopausal
women [118].
SERMs have been in clinical use for over 50 years
[119], and large clinical trials such as the STAR (Study of
Tamoxifen and Raloxifene) trial by the US National Can-
cer Institute have investigated the effects of SERMs on
reducing the incidence of breast cancer in 19,737 post-
menopausal women [120]. Research is therefore warranted
to examine the effects of these ligands on skeletal muscle
health and function in post-menopausal women who are at
risk of developing sarcopenia. To date there are limited
data on the effects of SERMs on skeletal muscle adaptation
or regeneration in humans. Subcutaneous tamoxifen treat-
ment induced estrogen-like protective effects on skeletal
muscle membrane integrity after electrical stimulation in
male and female rats [121]. Isolated human skeletal muscle
cells in culture respond to E2, tamoxifen and raloxifene
treatment with increased ERa and steroid receptor coacti-
vator (SRC) and decreased silencing mediator for retinoid
and thyroid hormone receptors (SMRT) mRNA expression
[91]. MyoD mRNA expression decreased in response to
both tamoxifen and raloxifene, and glucose transporter
(GLUT)-4 expression increased with raloxifene and
decreased with tamoxifen [91]. These findings suggest that
SERMs have differential effects on myogenic gene
expression pattern and these changes may be important for
the regulation of muscle growth and regeneration in post-
menopausal women.
There are reports on the abuse potential of SARMs for
doping purposes in sports [122]. However, more studies are
needed in patient populations to examine the effects of
exercise on SARM and SERM metabolism and the impli-
cations for signalling events in muscle cells.
4.2 Estrogen Receptor Subtype Selective Agonists
Estrogen-mediated cellular proliferation is primarily
transmitted through the ERa, which is also upregulated in
human breast cancer tissue [123]. Activation of the ERb
isoforms, on the other hand, reduces inflammation in
chronic inflammatory diseases and ERb-selective ligands
have the benefit of being non-uterotrophic and non-mam-
motrophic [124].
A number of studies from our laboratory using a rat
model of menopause (OVX) have shown that ER subtype
selective ligands induce protective effects in skeletal
muscle [3, 125, 126], intestinal cells [127] and bone [128].
By using both ER knockout mice and ER subtype selective
agonists, we found that the ERb isoform is primarily
responsible for inducing protective effects in skeletal
muscle after injury [3], in response to high-intensity
treadmill running exercise [125] or during nutrition-
induced obesity [126]. Our data also suggest that the ERb
isoform activates an anabolic transcriptional programme,
stimulating muscle hypertrophy in orchiectomized male
rats and OVX female rats [3, 126]. While another study has
also found beneficial effects of an ERa-selective ligand on
satellite cell activation after exercise-induced muscle injury
[74], there is accumulating evidence in favor of ERb
subtype selective agonists as therapeutic agents to reduce
inflammation in chronic inflammatory diseases [129, 130]
or to protect the intestinal tract from tumour development
by inducing anti-proliferative and pro-apoptotic effects
[127]. There are efforts underway to develop both steroidal
and non-steroidal ERb-selective agonists to treat inflam-
matory diseases [131].
Soy isoflavones display estrogenic activity based on
structural similarities to the natural ligand E2 and are
therefore referred to as phytoestrogens. The non-steroidal
phytoestrogen genistein binds with higher affinity to the
ERb compared with the ERa [132] and has been shown to
stimulate the expression of satellite cell markers in injured
skeletal muscle [3]. In addition, genistein has recently been
shown to act as an AR modulator. In AR reporter mice,
genistein was anti-androgenic in the prostate, testis and
brain of intact mice and pro-androgenic in the prostate and
brain of castrated mice [133]. The effects of isoflavones on
skeletal muscle growth appear to be concentration depen-
dent. Genistein affects cell growth by inhibiting protein

tyrosine kinases, such as the IGF-1 receptor. Cell culture
studies have shown that genistein has no effect on IGF-1
and IGF-1 receptor expression at dietary concentrations up
to 10 lmol/L [134], whereas proliferation rates of porcine
satellite cells are reduced when treated with genistein
concentrations [1 lmol/L [135]. In addition, genistein
affects muscle cell protein metabolism in a dose-dependent
manner, reducing protein synthesis at higher concentrations
(100 lmol/L genistein) and reducing protein degradation at
lower concentrations (0.1 lmol/L genistein) [136]. One
human study comparing the effects of 28 days of daily soy
and dairy milk ingestion on skeletal muscle inflammation
in post-menopausal women after muscle damaging down-
hill running exercise showed no significant effects of soy
ingestion on expression of inflammatory or proteolytic
genes [137]. The dose-dependent effects of isoflavones on
human skeletal muscle myogenic responses after exercise
remain to be determined.
5 Conclusion and Outlook
Aging is associated with a natural decline in sex hormone
levels in both men and women. Loss of muscle mass with
aging results in functional impairment and loss of inde-
pendence. Implications of the age-related hormonal
decline for skeletal muscle ultrastructural damage and
regeneration has been more clearly established in animal
than in human studies [3, 5, 138]. Inconsistent results
reported from human studies are ascribed to heteroge-
neous study populations and general sex-based differences
other than sex hormone status [83]. Despite these dis-
crepancies, there is convincing evidence in favour of sex
hormones promoting skeletal muscle homeostasis and
regeneration. Androgens are used as therapeutic agents to
reduce degeneration and enhance protein synthesis in
muscle dystrophy conditions and other wasting diseases,
such as HIV [99, 139]. Likewise, HRT creates a pro-
anabolic skeletal muscle environment in post-menopausal
women [68, 88]. Although some of underlying mecha-
nisms responsible for the anabolic effects of HRT have
been uncovered [88, 90], more work is necessary to
determine the effects of sex hormones on the expression
and activity of skeletal muscle myogenic and atrogenic
signalling molecules, in order to identify potential targets
for pharmacological interventions [140]. Since a classical
estrogen-containing HRT has been associated with an
increased breast cancer risk [141], ER subtype selective
ligands and tissue selective receptor modulators (SERMs,
SARMs) are developed to reduce proliferation in mitotic
tissues, such as the mammary gland and prostate, while
maintaining the estrogenic and androgenic benefits in
skeletal muscle and bone.
M. Velders, P. Diel
Studies have shown that estrogens and androgens impact
positively on satellite cell activation and proliferation
in vivo [3–5, 101]. Aging muscle maintains the ability to
recruit satellite cells in response to strength training [8].
Therefore, future studies should further investigate the
effects of combined hormonal and exercise interventions
on muscle health. Studies are also required to study the
effects of hormone therapy timing on muscle regeneration
and inflammation following exercise or disuse in older
people. Exercise science can contribute to this field by
investigating the effects of specific exercise regimens in
combination with hormonal therapies on estrogen- and
androgen-regulated molecular responses in skeletal muscle.
Acknowledgments The authors have no conflicts of interest rele-
vant to this review to declare. No specific funding sources were used
to write this manuscript.
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