Abstract

Background & Aims Per- and polyfluoroalkyl substances (PFAS) are persistent endocrine-disrupting chemicals associated with metabolic dysfunction, including metabolic dysfunction-associated steatotic liver disease (MASLD). While PFAS perturb lipid and bile acid (BA) metabolism in a sex-specific manner, the underlying mechanisms remain unclear. We tested whether steroid hormones mediate PFAS-associated metabolic alterations.

Methods In 104 patients with biopsy-characterized MASLD, we performed sex-stratified analyses applied liquid chromatography coupled to mass spectrometry (LC-MS) for chemical analysis, integrating circulating steroids, PFAS exposure, hepatic lipidomics and BA profiles.

Results Steroid hormones were associated with MASLD severity in a sexually-dimorphic manner. Dihydrotestosterone showed consistent inverse associations with steatosis, fibrosis, necroinflammation and insulin resistance, particularly in females. PFAS exposure was associated with altered steroid profiles, predominantly indicating suppressed steroidogenesis in females. These PFAS-associated hormonal changes were linked to downstream alterations in hepatic lipids and BAs. Mediation analysis supported indirect effects of PFAS on metabolic pathways via steroids, including testosterone/epi-testosterone-mediated effects on ether phospholipids and estradiol-mediated effects on lithocholic acid. Females exhibited stronger PFAS-steroid-BA associations, whereas males showed weaker, lipid-centric effects.

Conclusions PFAS exposure is associated with sex-specific disruption of steroid hormone pathways that may link environmental exposure to lipid and BA dysregulation in MASLD. These findings identify steroid hormones as potential key mediators of PFAS-associated metabolic dysfunction and highlight sex as a critical determinant in environmental liver disease.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

This study was supported by the 'Investigation of endocrine-disrupting chemicals as contributors to progression of metabolic dysfunction-associated steatotic liver disease' (EDC-MASLD) consortium funded by the Horizon Europe Program of the European Union under Grant Agreement 101136259 (to T.H. and M.O.), the Novo Nordisk Foundation (grant no. NNF20OC0063971 to T.H. and M.O.), Academy of Finland (grant no. 333981 to M.O. and no. 309263 to H.Y.-J.), Swedish Research Council (grant no. 2016-05176 to T.H and M.O), Juselius Foundation (to H.Y.-J.), the EPoS (Elucidating Pathways of Steatohepatitis) project funded by the Horizon 2020 Framework Program of the European Union (grant no. 634413, to M.O., H.Y.-J., and T.H.), the Swedish Knowledge Foundation (grant no. 20220122, to T.H. and M.O.), the Orion Research Foundation (to S.F.Q.), the Yrjoe Jahnsson Foundation (20207313 to S.F.Q.), the Maud Kuistila Memorial Foundation (2021-0301B to S.F.Q.), the Emil Aaltonen Foundation (210182 to S.F.Q.), the Finnish Medical Foundation (5843 to S.F.Q.), and the Biomedicum Helsinki Foundation (20230241 to S.F.Q.).

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The study protocol was approved by the Ethical Review Committee of the Hospital District of Helsinki and Uusimaa (284/13/03/01/13). The study was conducted in accordance with the Declaration of Helsinki. Each participant provided written informed consent after being explained the nature and potential risks of the study.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

Data availability statement

Data from the clinical study are available upon request and an appropriate institutional collaboration agreement.

AbbreviationsBile acidsBPAbisphenol ACAcholic acidCErsceramidesCYP7A1cholesterol 7a-hydroxylaseDCAdeoxycholic acidDGdiacylglycerolECenvironmental contaminantsEDCsendocrine-disrupting chemicalsGCAglycocholic acidGCDCAglycochenodeoxycholic acidHCAhyocholic acidHDCAhyodeoxycholic acidHexCershexosylceramidesHOMA-IRhomeostatic model assessment of insulin resistancehPPARahumanized PPARaIRinsulin resistanceLCAlithocholic acidLPCslysophosphatidylcholinesLPEslysophosphatidylethanolaminesMASLDmetabolic-dysfunction associated steatotic liver diseaseMASHmetabolic-dysfunction associated steatohepatitisPCsphosphatidylcholinesPEsphosphatidylethanolaminesPFASperfluorinated alkyl substancesPFHxSperfluorohexanesulfonic acidPFNAperfluorononanoic acidPFOAperfluorooctanoic acidPFOSperfluorooctanesulfonic acidSMssphingomyelinsTCAtaurocholic acidTCDCAtaurochenodeoxycholic acidTGtriacylglycerol11-KT11-Ketotestosterone11b-OHA411b-OH-Androstenedione11-KDHT11-Ketodihydrotestosterone11-KA411-KetoandrostenedioneDHEADehydroepiandrosteroneT/Epi-TTestosterone / (&) Epi-testosteroneANAndrosteroneDHTDihydrotestosteroneA4AndrostenedioneE2EstradiolE1EstroneECortisoneS11-DeoxycortisolBCorticosteroneAAldosterone17a-OHP517a-OH-Pregnenolone17a-OHP417a-OH-ProgesteroneDOC11-DeoxycorticosteroneP5PregnenoloneP4ProgesteroneAAndrogenes€EstrogensGGlucocorticosteroidsMmineralcorticosteroidsPProgesterones