Adverse Effects of Aromatase Inhibition on the Brain and Behavior in a Nonhuman Primate

J Neurosci. 2019 Jan 30;39(5):918-928. doi: 10.1523/JNEUROSCI.0353-18.2018. Epub 2018 Dec 26.


Breast cancer patients using aromatase inhibitors (AIs) as an adjuvant therapy often report side effects, including hot flashes, mood changes, and cognitive impairment. Despite long-term use in humans, little is known about the effects of continuous AI administration on the brain and cognition. We used a primate model of human cognitive aging, the common marmoset, to examine the effects of a 4-week daily administration of the AI letrozole (20 μg, p.o.) on cognition, anxiety, thermoregulation, brain estrogen content, and hippocampal pyramidal cell physiology. Letrozole treatment was administered to both male and female marmosets and reduced peripheral levels of estradiol (E2), but unexpectedly increased E2 levels in the hippocampus. Spatial working memory and intrinsic excitability of hippocampal neurons were negatively affected by the treatment possibly due to increased hippocampal E2. While no changes in hypothalamic E2 were observed, thermoregulation was disrupted by letrozole in females only, indicating some impact on hypothalamic activity. These findings suggest adverse effects of AIs on the primate brain and call for new therapies that effectively prevent breast cancer recurrence while minimizing side effects that further compromise quality of life.SIGNIFICANCE STATEMENT Aromatase inhibitors (AIs) are used as an adjuvant therapy for estrogen-receptor-positive breast cancer and are associated with side effects, including hot flashes, depression/anxiety, and memory deficits severe enough for many women to discontinue this life-saving treatment. AIs are also used by men, yet sex differences in the reported side effects have not been systematically studied. We show that AI-treated male and female marmosets exhibit behavioral changes consistent with these CNS symptoms, as well as elevated hippocampal estradiol and compromised hippocampal physiology. These findings illustrate the need for (1) a greater understanding of the precise mechanisms by which AIs impact brain function and (2) the development of new treatment approaches for breast cancer patients that minimize adverse effects on the brain.

Keywords: anxiety; aromatase inhibitors; hippocampal physiology; neuroestradiol; spatial working-memory; thermoregulation.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Animals
  • Anxiety / chemically induced
  • Anxiety / psychology
  • Aromatase Inhibitors / adverse effects*
  • Behavior, Animal / drug effects*
  • Body Temperature Regulation / drug effects
  • Brain / drug effects*
  • Brain Chemistry / drug effects
  • Callithrix
  • Cognition / drug effects
  • Estradiol / metabolism
  • Estrogens / metabolism
  • Hippocampus / cytology
  • Hippocampus / drug effects
  • Letrozole / adverse effects*
  • Psychomotor Performance / drug effects
  • Pyramidal Cells / drug effects
  • Sex Characteristics


  • Aromatase Inhibitors
  • Estrogens
  • Estradiol
  • Letrozole