Phthalates Exposure and Endocrinal Effects: An Epidemiological Review

Abstract

Phthalates are ubiquitous endocrine disruptors which may cause potential health effects in general populations. We explored 3 scientific databases (PubMed, Medline, and ScienceDirect) to search epidemiological studies focused on phthalates exposure and the important health effects including endocrine, hormonal regulation of thyroid and steroid, reproductive effects, pregnancy, precocious puberty, obesity, and infertility in human. Some studies demonstrated negative association between phthalate levels and sex steroid hormones (testosterone, LH), thyroid hormones (thyroxine), sperm quality, anogenital distance, gestational age and neurodevelopment (cognitive function and intelligence quotient), although most of them have some limitations. A few studies showed positive association between phthalate levels and precocious puberty, pregnancy loss, obesity, leiomyoma, although results of some studies were not consistent. In summary, phthalates may affect reproductive and sex hormones, thyroid function and development. Although large-scale cohort studies are needed to clarify the association, it is necessary to reduce the phthalates exposure in pregnant women and young children to prevent unexpected consequences of reproductive and development effects in the offspring.

Full text

Journal of Food and Drug Analysis, Vol. 20, No. 4, 2012, Pages 719-733
719
doi:10.6227/jfda.2012200401
Phthalates Exposure and Endocrinal Effects:
An Epidemiological Review
PO-CHIN HUANG1, SAOU-HSING LIOU2, ING-KAN HO3, HUNG-CHE CHIANG1,2,
HSIN-I HUANG2 AND SHU-LI WANG2*
1. National Environmental Health Research Center (NEHRC), National Health Research Institutes, Miaoli, Taiwan, R.O.C.
2. Division of Environmental Health and Occupational Medicine, National Health Research Institutes, Miaoli, Taiwan, R.O.C.
3. Division of Mental Health and Substance Abuse Research, National Health Research Institutes, Miaoli, Taiwan, R.O.C.
(Received: April 20, 2012; Accepted: July 3, 2012)
ABSTRACT
Phthalates are ubiquitous endocrine disruptors which may cause potential health effects in general populations. We explored 3 scien-
tific databases (PubMed, Medline, and ScienceDirect) to search epidemiological studies focused on phthalates exposure and the important
health effects including endocrine, hormonal regulation of thyroid and steroid, reproductive effects, pregnancy, precocious puberty, obesity,
and infertility in human. Some studies demonstrated negative association between phthalate levels and sex steroid hormones (testosterone,
LH), thyroid hormones (thyroxine), sperm quality, anogenital distance, gestational age and neurodevelopment (cognitive function and
intelligence quotient), although most of them have some limitations. A few studies showed positive association between phthalate levels
and precocious puberty, pregnancy loss, obesity, leiomyoma, although results of some studies were not consistent. In summary, phthalates
may affect reproductive and sex hormones, thyroid function and development. Although large-scale cohort studies are needed to clarify the
association, it is necessary to reduce the phthalates exposure in pregnant women and young children to prevent unexpected consequences
of reproductive and development effects in the offspring.
Key words: phthalate, endocrine, reproduction, thyroid function, neurodevelopment, infertility
INTRODUCTION
Phthalates are considered endocrine disrupting chemi-
cals in many aspects, including estrogenic, anti-androgenic,
and anti-thyroid activites(1-3). They are suspected to inter-
fere with the production, activation and excretion of natural
hormones in human, especially in reproductive system.
Phthalates are added to plastics to make them soft and
exible, to cosmetics as a vehicle for fragrances, and to many
other daily products, including building materials, children’s
toys, and medical devices(4). Recent reports have shown that
phthalates are widely added in considerable amounts (up to
5%) to cosmetics and personal care products, which raise
the levels of urinary phthalates metabolites rapidly when
these products are used daily(5,6), particularly in women.
The potential consequences of human exposure to phthalates
have raised concerns in the general population and have been
studied in susceptible subjects, such as pregnant women,
infants, and children(7-9).
Phthalates are estrogenic and anti-androgenic endocrine
disruptors that may prolong menstrual cycles and increase
the proportion of premature menopause in animal models(1,2).
Toxicological evidence has shown that some phthalates, such
as butyl benzyl phthalate (BBzP; BBP), di-n-butyl phthalate
(DnBP;DBP), and di-(2-ethylhexyl) phthalate (DEHP),
may alter or mimic estradiol (E2) in vivo and in vitro(10-12).
However, whether phthalate exposure results in adverse
effects on human reproductive system remains largely
unknown.
Toxicological evidence showed that the fetus is exposed
to some phthalates, such as DBP, diethyl phthalate (DEP),
and DEHP, all of which penetrate the placenta(13-15). In addi-
tion, prenatal exposure to phthalates, such as DnBP, BBzP,
and DEHP, during the critical window of gestation in male
rodents had a reproductively toxic effect on sexual differen-
tiation and caused decreased fertility in offspring(16-23).
In May 2011, the illegal use of DEHP as clouding agent in
foods and beverages was reported in Taiwan(24). It raised the
concerns on health effects of phthalates in human, especially
in susceptible population. Numerous epidemiological studies
* Author for correspondence. Tel: +886-37-246166 ext. 36509;
Fax: +886-37-587-406; Email: slwang@nhri.org.tw

Journal of Food and Drug Analysis, Vol. 20, No. 4, 2012
720
THE 20TH ANNIVERSARY ISSUE
have been conducted to investigate the relationship between
phthalates exposure in human and health outcomes, including
hormonal regulation of steroid and thyroid hormones, repro-
ductive effects, pregnancy, precocious puberty, obesity and
infertility. A systematic overview of published literatures
is needed for directing future research and also provides a
comprehensive discussion of potential effects in the general
population.
MATERIALS AND METHODS
PubMed, Medline and ScienceDirect databases were
searched for epidemiological studies focused on phthalates
exposure and hormones (thyroid and steroid), reproductive
effects, obesity, pregnancy, precocious puberty, and infertility
in human. Several potential health effects in human were
discussed and listed as follow:
I. Sex Hormone and Reproductive Outcomes
II. Thyroid Hormones
III. Pregnancy Outcomes
IV. Precocious Puberty
V. O b e s i t y
VI. Neurodevelopment
VII. Infertility (Female: Gynecological Diseases; Male:
Semen Quality)
The names, chemical structures and abbreviations of
phthalates and phthalate metabolites were shown in Figure 1
and Figure 2, respectively.
I. Sex Hormone and Reproductive Outcomes
The observation of reproductive health in human
studies included sex hormones and examination of repro-
ductive organs. Sex hormones are likely to be affected by
the prenatal and postnatal exposure to phthalates (Table
1.1). One study showed that the maternal urinary levels of
mono-(2-ethylhexyl) phthalate (MEHP) and mono-(2-ethyl-
5-hydroxyhexyl) phthalate (MEHHP) were negatively corre-
lated with the free testosterone (fT) and fT/ estrodial (E2)
levels in cord serum of female newborns(25) and suggested
an anti-androgenic effect of phthalates during pregnancy.
Another study revealed that mono-n-butyl phthalate (MnBP),
mono-ethyl phthalate (MEP), and mono-methyl phthalate
(MMP) levels in breast milk were signicantly positively
associated with the luteinizing hormone (LH)/fT and mono-
iso-nonyl phthalate (MiNP) with increasing level of LH in
infant at three months of age. Besides, MnBP level in breast
milk was negatively associated with fT in infant(26).
There is no direct and strong evidence to show the linkage
between phthalates exposure and reproductive diseases, such
as cryptorchidism, hypospadias or undescended testis. No
signicant association was found between prenatal phthalates
exposure and hypospadias and undescended testis from 284
Figure 1. Names, numbering and chemical structures of eight phthalates frequently discussed in the reviewed epidemiological studies.
H
2
CC
H
O
O
O
CH
2
H
2
C
H
2
C
H
2
CCH
3
H
2
CH
C
O
H
2
C
H
2
C
H
2
CCH
3
CH
2
CH
3
CH
3
Di-(2-ethylhexyl) phthalate (DEHP; CAS no.:
117-81-7))
H
2
C
H
2
C
O
O
O
H
2
CCH
3
H
2
C
H
2
C
O
H
2
CCH
3
Di-n-butyl phthalate (DnBP; CAS no.: 84-74-2)
O
O
O
O
CH2
CH
CH2
CH
H3C CH3
H3C CH3
Di-iso-butyl phthalate (DiBP; CAS no.: 84-69-5)
H
2
C
H
2
C
O
O
O
H
2
CCH
3
H
2
C
H
2
C
O
Butyl benzyl phthalate (BBzP; CAS no.: 85-68-7)
H
2
CCH
3
O
O
O
H
2
CCH
3
O
Di-ethyl phthalate (DEP; CAS no.: 84-66-2)
CH
3
O
O
O
CH
3
O
Di-methyl phthalate (DMP; CAS no.: 131-11-3)
H
2
C
H
2
C
O
O
O
H
2
C
H
2
C
H
2
C
H
2
C
H
2
C
H
2
C
O
H
2
C
H
2
C
H
2
C
H
2
C
H
2
CCH
3
H
2
CCH
3
Di-n-octyl phthalate (DnOP; CAS no.: 117-84-0)
H
2
C
H
2
C
O
O
O
H
2
CC
H
H
2
C
H
2
C
H
2
C
H
2
C
O
H
2
CH
C
H
2
C
H
2
C
CH
3
CH
3
H
2
CCH
3
H
2
CCH
3
Di-iso-nonyl phthalate (DiNP; CAS no.: 58033-90-2)
Figure 1. Names, numbering and chemical structures of eight phthalates frequently discussed in the reviewed epidemiological studies.

Journal of Food and Drug Analysis, Vol. 20, No. 4, 2012
721
THE 20TH ANNIVERSARY ISSUE
boys in France(27). Similarly, no signicant association was
found between phthalate metabolites levels in breast milk and
cryptorchidism in boys(26).
Anogenital distance (AGD) is an indicator of in utero
androgenic exposure(28) and has been added to the US EPA
testing guidelines for reproductive toxicity studies(29-32).
Therefore, AGD has been used as an index for evaluation of
androgenic effects in epidemiological studies. In the United
States, Swan et al. rst reported a decrease in AGD among male
infants (85 boys aged 2-36 months) with prenatal phthalate
exposure(33) (Table 1.2). Four phthalate metabolites, MnBP,
mon-iso-butyl phthalate (MiBP), MEP and mono-benzyl
phthalate (MBzP) were negatively associated with anogenital
index (AGI), AGD divided by birth weight. In a further and
multi-center cohort study, collected urine samples from 136
pregnant US women were tested for 9 phthalate metabolites
(MnBP, MBzP, mono-(3-carboxypropyl) phthalate (MCPP),
MEP, MiBP, MMP, MEHHP, MEHP, mono-(2-ethyl-5-
oxohexyl) phthalate (MEOHP)) and AGDs were measured
in their male infants at 2-36 months(34). A signicant asso-
ciation was reported between AGD and three metabolites
of DEHP: MEHHP, MEHP, MEOHP, as well as their sum.
Figure 2. Names, abbreviations and chemical structures of phthalate metabolites frequently discussed in the reviewed epidemiological studies.
Metabolites of DEHP (A, B, C, D); DnBP (E); DiBP (F); BBzP (G); DEP (H); DMP (I); DnOP (J); DiNP (K).
OH
H
2
CC
H
O
O
O
H
2
C
CH3
H
2
C
H
2
C
H
2
CCH
3
A. Mono-methyl phthalate
(MEHP)
OH
H2
CC
H
O
O
O
CH2
H2
C
H2
C
H2
C
H2
C
CH3
OH
B. Mono-(2-ethyl-5-hydroxyhexyl) phthalate
(MEHHP)
OH
H
2
CC
H
O
O
O
CH
2
H
2
C
H
2
CCCH
3
CH
3
O
C. Mono-(2-ethyl-5-oxohexyl) phthalate
(MEOHP)
OH
H
2
CC
H
O
O
O
CH
2
H
2
C
H
2
C
H
2
CC
CH
3
O
OH
D. Mono-(2-ethyl-5-carboxypentyl)
phthalate (MECPP)
H
2
C
H
2
C
O
O
O
H
2
CCH
3
OH
E. Mono-n-butyl phthalate (MnBP)
O
O
O
OH
CH2
CH
H3C CH3
F. Mono-iso-butyl phthalate (MiBP)
OH
O
O
H2
C
H2
C
O
G. Mono-benzyl phthalate (MBzP)
H
2
CCH
3
O
O
O
OH
H. Mono-ethyl phthalate (MEP)
CH
3
O
O
O
OH
I. Mono-methyl phthalate (MMP)
OH
H
2
C
H
2
C
O
O
O
H
2
CC
O
OH
J. Mono-(3-carboxypropyl) phthalate
(MCPP)
H
2
C
H
2
C
O
O
O
H
2
CC
H
H
2
C
H
2
C
OH
CH
3
H
2
CCH
3
K. Mono-iso-nonyl phthalate (MiNP)
Figure 2. Names, abbreviations and chemical structures of phthalate metabolites frequently discussed in the reviewed epidemiological studies. Metabolites of
DEHP (A, B, C, D); DnBP (E); DiBP (F); BBzP (G); DEP (H); DMP (I); DnOP (J); DiNP (K).
Table 1.1. Epidemiological studies on phthalates exposure and reproductive hormones/organ
Country / Subjects Exposure/ Biomarkers Results References
Taiwan/
155 paired pregnant
women and newborns
Urine/
MEP, MEHP, MEHHP
In female newborns, the maternal urinary
MEP, MEHP, MEHHP:  fT↓ (r=-0.24~ -0.32)
MEP, MEHP, MEHHP:  fT/E2↓ (r=-0.27~ -0.30)
Lin 2011(25)
Denmark/
130 infants
(62 cryptorchid;
68 healthy boys)
Breast milk (1-3 months)
MBP, MEP, MMP, MiNP
MEP, MBP:  SHBG↑
MEP, MMP, MBP:  LH/ fT↑
MBP:  fT↓(p=0.033)
MiNP:  LH↑
Main 2006(26)
France/
21 hypospadias and 50
undescended testis boys
at birth. 213 matched
controls.
Urine/
MEP, MBP, MiBP, MEHP,
MEOHP, MEHHP,
MECPP, MCNP, MCOP,
MBzP, MCPP.
No evidence of association (ptrend>0.10) with urinary concentrations
of phthalates metabolites was observed for undescended testis risk.
Decreased risk of hypospadias, not statistically significant, was
observed with urinary concentrations of both low- and high-molecu-
lar-weight phthalate metabolites (ptrend, 0.13 and 0.10, respectively).
Chevrier 2012(27)
Abbreviations: E2— estradiol; fT— free testosterone; MBP— mono-butyl phthalate; MEP— mono-ethyl phthalate; MEHP— mono-2-ethyl-
hexyl phthalate; MEHHP— mono-(2-ethyl-5-hydroxyhexyl) phthalate; MEOHP— mono-(2-ethyl-5-oxohexyl) phthalate; MiNP—mono-i-nonyl
phthalate; LH—luteinizing hormone; SHBG—sex hormone binding globin.

Journal of Food and Drug Analysis, Vol. 20, No. 4, 2012
722
THE 20TH ANNIVERSARY ISSUE
DEHP metabolite was signicantly and inversely related to
testicular descent.
In Mexico, Bustamante-Montes et al. collected urine
samples from 73 pregnant Mexican women for four phthalate
metabolites (MEHP, MBzP, MEP, MBP) levels(35). They
reported statistically signicant and negative association
between MEP and AGD, and also between MBzP and penis
length and width. In Taiwan, Huang et al. collected amniotic
uid samples from 65 pregnant Taiwanese women for ve
phthalate metabolites levels(36). They found a signicantly
negative correlation between amniotic uid MBP and both
AGD (R=-0.31, p<0.05), and AGI (R=-0.32, p<0.05) in girls,
and suggested in utero exposure to phthalates in general has
feminine effects on the fetus. In Japan, Suzuki et al. collected
urine samples from 111 pregnant Japanese women for seven
phthalate metabolite levels(37). They reported that log-trans-
formed MEHP (specic gravity-corrected) had signicantly
negative association with AGI and suggested that prenatal
exposure to DEHP affects reproductive development in males.
Current reviewed studies showed consistent anti-androgenic
effects (reproductive hormones and AGD) of DEHP and DBP
metabolites in human fetus and newborns.
II. Thyroid Hormones
Thyroid hormone is essential for human development of
the brain, neurons, growth and development of other organs
in children. Hypothyroidism in childhood is accompanied
by severe growth retardation, like cretinism. Experimental
studies showed potential anti-thyroid effects in certain
phthalates. Currently, there are only four studies focusing on
this issue in pregnant women(38), adults(39,40) and young chil-
dren(41) (Table 2). In Taiwan, Huang et al. found that urinary
MnBP level in pregnant women was signicantly nega-
tive associated with free thyroxin (FT4) and thyroxin (T4)
(FT4: β=-0.110; T4: β=-0.112, p<0.05), and suggested that
exposure to DnBP might affect thyroid activity in pregnant
women(38). In the United States, Meeker et al. also reported
Table 2. Epidemiological studies on phthalates exposure and thyroid function
Country/ Subjects Exposure/ Biomarkers Results References
USA/
1,346 adults (≧20 years)
329 adolescents
(12-19 years)
Urine/
MCPP, MECPP,
MEHP, MEHHP,
MEOHP,
MEHP, MEHHP, MEOHP, MECPP, MCPP:  total T4↓(Ptrend<0.001)
MEHP, MEHHP, MEOHP, MECPP:  total T3 ↓
MECPP:  FT4 ↓
MEHP, MEHHP, MEOHP, MECPP:  TBG ↓
MEHHP, MEOHP, MECPP:  TSH↑
Meeker 2011(40)
Denmark/
845 children (4-9 years)
Urine/
MEP, MBP, MBzP,
MCiOP, ΣDEHP
ΣDEHP, MCiOP:  IGF-1 ↓(in boys)
MEP, MBP, MBzP, MCiOP:  total T3 ↓
MEP, MBP, MBzP, MCiOP, ΣDEHP:  FT3 ↓
Boas 2010(41)
USA/
408 Men (18-55 years)
Urine/
MEHP
MEHP:  FT4 ↓ ;  T3 ↓Meeker 2007(39)
Taiwan/
76 pregnant women
Urine/
MBP
MBP:  T4 ↓;  FT4 ↓(FT4: β=-0.110, p<0.001; T4: β=-0.112,
p=0.003).
Huang 2007(38)
Abbreviations: DEHP— di-(2-ethylhexyl) phthalate; FT3— free triiodothyronine; FT4— free thyroxine; IGF-1—insulin-like growth factor-1;
MBP— mono-butyl phthalate; MBzP — monobenzyl phthalate; MCiOP— monocarboxyisooctyl phthalate; MEP— mono-ethyl phthalate;
MECPP— mono-2-ethyl-5-carboxypentyl phthalate; MEHP— mono-(2-ethylhexyl) phthalate; MEHHP — mono-(2-ethyl-5-hydroxylhexyl)
phthalate; MEOHP— mono-(2-ethyl-5-oxo-hexyl) phthalate; T3— triiodothyronine; T4— thyroxine; TBG— thyroxine-binding globulin; TSH—
thyroid stimulating hormone.
Table 1.2. Epidemiological studies on phthalates exposure and genital development in neonates
Country/ Subjects Exposure/ Biomarkers Results References
Japan/
111 maternal-infant pairs
Urine/
MEHP
MEHP:  AGI↓Suzuki 2011(37)
Taiwan/
65 maternal-infant pairs
Amniotic fluid & urine/
MBP
MBP:  amniotic fluid↑ material urine
Amniotic fluid MBP:  AGI↓; AGD↓
Huang 2009(36)
Mexico/
73 maternal-infant pairs
Urine/
MEP; MBzP
MEP:  AGD↓
MBzP penis length and width↓
Bustamante-Montes
2008(35)
USA/
134 maternal-infant (boy) pairs
Urine/
MEHP, MEHHP, MEOHP
MEHP, MEHHP, MEOHP:  AGD↓, testicular descent Swan 2008(34)
USA/
85 maternal-infant (boy) pairs
Urine/
MEP, MnBP, MBzP, MiBP
MBzP, MEP, MnBP, MiBP:  AGI↓(OR=3.8, 4.7, 10.2
and 9.1, respectively, all p-values<0.05).
Swan 2005(33)
Abbreviations: AGI— anogential index; AGD— anogenital distance; MBP— mono-butyl phthalate; MBzP— mono-benzyl phthalate; MEP—
mono-ethyl phthalate; MEHP— mono-2-ethylhexyl phthalate; MEHHP— mono-(2-ethyl-5-hydroxyhexyl) phthalate; MEOHP— mono-(2-ethyl-
5-oxohexyl) phthalate; MiBP— mono-i-butyl phthalate; MnBP— mono-n-butyl phthalate.

Journal of Food and Drug Analysis, Vol. 20, No. 4, 2012
723
THE 20TH ANNIVERSARY ISSUE
a negative association between T4 and urinary MEHP level
in male adults(39). He further showed signicant inverse and
dose-dependent relationships between T4 and urinary DEHP
metabolites in adults from the National Health and Nutrition
Examination Survey (NHANES) 2007-2008, whereas signif-
icant positive relationship between DEHP metabolites and
total triiodothyronine (T3) was found among adolescents(40).
In Denmark, another study found that the levels of urinary
phthalate metabolites was associated with thyroid function,
insulin-like growth factor I (IGF-I), and growth parameters
in children(41). In girls, phthalate metabolites were nega-
tively associated with serum levels of free and total T3, while
metabolites of DEHP and di-iso-nonyl phthalate (DiNP)
were negatively associated with IGF-I in boys. There were
some lines of evidence showed possible anti-thyroid activi-
ties of DnBP and DEHP in susceptible and general popula-
tion. Although growing animals and cell models provided
supporting evidence on anti-thyroid activities of phthalates,
more and large-scale follow-up perspective studies are needed
to elucidate the impacts on human health.
III. Pregnancy Outcomes
Animal studies indicated that some phthalate metabo-
lites may harm female reproductive function during preg-
nancy and affect fetal health. Table 3 showed summarized
results of epidemiological studies on phthalates exposure and
pregnancy outcomes. Latini et al. rstly reported newborns
(n=84) with cord blood MEHP-positive showed a signi-
cantly lower gestational age compared to those with unde-
tectable MEHP(8). They further showed a signicant and
positive correlation between detectable MEHP in cord blood
and decreased gestational age at delivery (OR=1.50; 95% CI:
1.01-2.21). No signicant association with birth weight was
found for either DEHP or MEHP in these 84 infants. In the
United States, Wolff et al. showed that low-molecular-weight
(LMW) phthalate metabolites in pregnant women at the third
trimester were positively associated with gestational age:
0.97 (95% CI: 0.07-1.9) and head circumference: 0.13 (95%
CI: 0.01-0.24)(42). An increased risk of pregnancy loss (n=48,
Hazard Ratio (HR): 2.11; 95% CI: 1.07-4.16) was found
among women with MEHP in the upper tertile compared
with those in the lowest tertile(43). The risk of subclinical
embryonal loss (n=32) was 16.54 (95% CI: 2.22-123.3) while
the risk of clinical spontaneous abortion (n=16) decreased
(HR: 0.17; 95% CI: 0.04-0.76). Limited studies showed that
phthalate exposure during pregnancy may affect pregnancy
loss or gestational age of pregnant women and raise the health
concern of fetus or embryo development. Most of studies
were conducted with relatively small or limited sample size.
I V. Precocious Puberty
The onset of puberty girl included some physical signs,
such as enlargement of breast, ovaries, uterus and growth
of pubic hair. Precocious puberty, or early onset of puberty,
is associated with the development of breast cancer(44) and
physical development. Therefore, precocious puberty (before
9 years old) in girls is of great concern. Table 4 showed
summarized results of epidemiological studies on phthalates
exposure and precocious puberty. In Puerto Rico, Colón et al.
rst reported that levels of phthalates, particularly DEHP, in
serum of Puerto Rico girls with premature thelarche (n=41)
were signicantly higher compared with the control girls
(n=35)(45). In China, DEHP levels in girls with precocious
puberty (n=110) were found to be higher compared with the
Table 3. Epidemiological studies on phthalates exposure and pregnancy outcome.
Country/ Subjects Exposure/ Biomarkers Results References
Italy/
84 newborns
Serum (Cord blood)/
MEHP
MEHP:  gestational age ↓(OR=1.50; 95% CI: 1.013-2.21;
p=0.043)
Latini 2003(8)
USA/
404 pregnant women
Urine/
MBP, MEP, MiBP,
MMP, MEHP, MBzP
Low-molecular-weight phthalate metabolites (low-MWP):
 gestational age ↑(β=0.14, p<0.05);  head circumference↑(β=0.13,
p<0.05).
MEHP:  gestational age ↑(β=0.15, p<0.05)
MEP:  head circumference ↑(β=0.12, p<0.05)
MBzP:  Birth length↑(β=0.20, p<0.05)
Wolff 2008(42)
Japan/
149 pregnant women
Urine/
9 phthalate metabolites
The relationships between prenatal exposure to phthalate esters and
birth outcomes were not significant.
Suzuki 2010(93)
Mexico/
60 pregnant women
Urine/
MBP, MBzP, MCPP,
MEHP, MEHHP,
MEOHP, MECPP
After correction by specific gravity or creatinine, geometric mean
urinary concentrations were higher for MBP, MBzP, MCPP, MEHP,
MEHHP, MEOHP and MECPP among women who subsequently
delivered preterm.
Meeker 2009(94)
Denmark, Sweden/
128 pregnant women
Urine/
MEHP
MEHP:  pregnancy loss ↑(n=48, OR=2.9; 95% CI: 1.1-7.6). Toft 2012(43)
Abbreviations: CI— confident interval; MBP— mono-butyl phthalate; MBzP— mono-benzyl phthalate; MCPP— mono-(3-carboxypropyl)
phthalate; MEP— mono-ethyl phthalate; MECPP— mono(2-ethyl-5-carboxypentyl) phthalate; MEHP— mono-2-ethylhexyl phthalate;
MEHHP— mono-(2-ethyl-5-hydroxyhexyl) phthalate; MEOHP— mono-(2-ethyl-5-oxohexyl) phthalate; MiBP— mono-i-butyl phthalate;
OR— odds ratio.

Journal of Food and Drug Analysis, Vol. 20, No. 4, 2012
724
THE 20TH ANNIVERSARY ISSUE
control group (n=100). Girls with higher DEHP levels have
larger ovarian and uterus size(46). In Taiwan, urinary MMP
level was signicantly higher in premature thelarche group
(n=30) than in the control group (n=33)(47). In the United
States, no signicant difference in levels of nine phthalate
metabolites (MBP, MBzP, MCPP, MECPP, MEHP, MEHPP,
MEOHP, MiBP, MEP) was found in central precocious
puberty (CPP) (n=28) and prepubertal females (n=28)(48). In
Turkey, Durmaz et al. showed that plasma DEHP and MEHP
levels were signicantly higher in the pubertal gynecomastia
group (n=40) compared with the control group (n=21).
However, no association was found between plasma DEHP
and MEHP levels and any of the examined hormone levels
(LH, follicle-stimulating hormone (FSH), E2, prolactin,
thyrotropin, FT3, FT4) in Turkey’s children(49). In the United
States, a multiethnic longitudinal study of 1,151 girls (6-8
years of age) from ve cities was enrolled (2004-2007) to
investigate the associations of phthalate exposures with
pubertal stages(50). They found that high-molecular-weight
(HMW) phthalate metabolites were weakly associated with
pubic hair development and a positive trend was observed
for LMW phthalate metabolites with breast and pubic hair
development.
Results of case-control and cross-sectional studies indi-
cated that the levels of DEHP or MEHP were signicantly
higher in the premature thelarch and precocious puberty
groups compared with the controls. However, no denite
conclusion can be drawn at present, due to lack of consid-
eration of other important factors, such as diet and nutrition.
V. Obesity
Obesity is closely linked to metabolic syndrome and
numerous diseases, including type II diabetes, cardiovascular
diseases, certain cancers and mortality(51). Experimental
studies showed the anti-androgenic effects of phthalate in
rodent. Testosterone affects the body fat distribution and
decreases the insulin sensitivity in men. Experimental studies
in males have shown that testosterone administration reduces
lipid uptake by intra-abdominal fat(52) and also reduces
visceral fat and improves insulin sensitivity(53-55). Besides,
another possible mechanism is the disruption of thyroid
function, which is responsible for the maintenance of basal
metabolism. Phthalates are suspected thyroid disruptors and
Table 4. Epidemiological studies on phthalates exposure and precocious puberty
Country/ Subjects Exposure/ Biomarkers Results References
Puerto Rico/
41 thelarche patients &
35 control
Serum/
DMP, DEP, DBP,
DEHP,MEHP
DMP, DEP, DBP, DEHP and MEHP:  premature thelarche ↑ Colón 2000(45)
China/
110 precocious girls &
100 control children
Serum/
DBP, DEHP
In precocious girls:
DBP:  uteruses ↑(r=0.456, p<0.05); ovaries ↑(r=0.378, p<0.01).
DEHP:  uteruses ↑(r=0.382, p<0.05); ovaries ↑(r=0.689, p<0.01).
Qiao 2007(46)
Taiwan/
30 girls with premature
thelarche, 26 with CPP,
and 33 normal controls
Urine/
MBP, MEHP, MMP
MMP:  premature thelarche↑
MBP:  intake of seafood, drink and the use of plastic cups.
MEHP:  intake of seafood and meat and exposure plastic handi-wrap.
Chou 2009(47)
USA/
28 central precocious
puberty and 28 age &
race-matched prepuber-
tal girls.
Urine/
MnBP, MBzP, MCPP,
MECPP,MEHP,
MEHPP, MEOHP,
MiBP, MEP
No significant differences between the children with central precocious
puberty and the controls in either absolute or creatinine normalized
concentrations of any of the 9 phthalate metabolites were found
Lomenick 2010(48)
Turkey/
40 diagnosed pubertal
gynecomastia, 21
age-matched control
children
Plasma/
DEHP, MEHP
DEHP:  pubertal gynecomastia↑(OR=2.77; 95% CI: 1.48-5.21).
MEHP:  pubertal gynecomastia↑(OR=24.8; 95% CI: 3.5-172.6).
Durmaz 2010(49)
USA/
1,151 girls (6-8 years)
Urine/
MEP, MnBP, MiBP,
MBzP, MCPP,
MECPP, MEHHP,
MEOHP, MEHP
High-molecular-weight phthalate (high MWP) metabolites were weakly
associated with pubic hair development (PRadjusted=0.94; 95% CI: 0.88-
1.00, fifth vs. first quintile).
Small inverse associations were seen for high MWP with pubic hair
stage; a positive trend was observed for low MWP biomarkers with
breast and pubic hair development.
In the first enterolactone quintile, for the association of high BMI with
any development, the PR was 1.34 (95% CI, 1.23-1.45 vs. low BMI).
Wolff 2010(50)
Abbreviations: BMI—body mass index; BBP— butyl benzyl phthalate; CI— confident interval; CPP—central precocious puberty; DBP—
di-butyl phthalate; DEP— di-ethyl phthalate; DEHP— di-(2-ethylhexyl) phthalate; MBP— mono-butyl phthalate; MBzP— mono-benzyl
phthalate; MCPP— mono-(3-carboxypropyl) phthalate; MEP— mono-ethyl phthalate; MECPP— mono-(2-ethyl-5-carboxypentyl) phthalate;
MEHP— mono-2-ethylhexyl phthalate; MEHHP— mono-(2-ethyl-5-hydroxyhexyl) phthalate; MEOHP— mono-(2-ethyl-5-oxohexyl) phthalate;
MiBP— mono-i-butyl phthalate; MnBP— mono-n-butyl phthalate; MMP: mono-methyl phthalate; OR— odds ratio; PR— prevalence ratios.

Journal of Food and Drug Analysis, Vol. 20, No. 4, 2012
725
THE 20TH ANNIVERSARY ISSUE
may reduce circulating thyroid levels(56). There is a growing
concern about the effects of phthalates on obesity and cardio-
vascular disease.
Table 5 showed summarized results of phthalates expo-
sure and obesity in epidemiological studies. Stahults et al.
rstly reported four metabolites (MBzP, MEHHP, MEOHP,
and MEP) were associated with increased waist circumfer-
ence (WC) and three with increased HOMA (MBP, MBzP, and
MEP) from US male adults (NHANES 1999-2002, n=1451)
(57). They suggested that exposure to these phthalates may
contribute to the population burden of obesity, insulin resis-
tance, and related clinical disorders. Another study presented
their ndings between levels of six phthalate metabolites
and body mass index (BMI) and WC using data from
NHANES(58). They found positive associations between BMI
and WC among adult males for most phthalate metabolites,
like MBzP. In females, BMI and WC increased with quar-
tiles of MEP in 12-19 year olds, and a similar but less strong
pattern was seen in 20-59 year olds. By contrast, higher levels
of MEHP were associated with lower BMI in adolescent
girls and females aged 20-59. Only little evidence revealed
possible linkage between phthalate exposure and obesity in
adults and adolescence. No denite conclusion can be drawn
at present due to being devoid of other important factors, such
as diet, smoking, activity and alcohol consumption.
VI. Neurodevelopment
Laboratory experiments with rodents have revealed
that higher levels of DEHP may have adverse effects on
neurobehavioral parameters. While the widely application
and exposure of phthalates in human, the adverse effects of
phthalates on children’s neurodevelopment raise the public
health concern, such as intelligence quotient (IQ), behavior
and attention-decit/hyperactivity disorder (ADHD). Some
epidemiological studies have examined phthalates exposure
in relation to neurodevelopment among neonates after birth
in United States and Mexico(59-61), in Korea in children from
elementary schools(62-64) and in United States both among
children 4-9 years(65) and 3.6-6.4 years of age(66) (Table 6).
In the United States, a study was performed among
neonates enrolled in a multiethnic birth cohort at the Mount
Sinai School of Medicine; urinary concentrations of phthalate
metabolites in pregnant women and neonatal behaviors
measured within 5 days of birth using the Brazelton Neonatal
Behavioral Assessment Scale were assessed. They showed
strong and inverse associations between increasing concen-
trations of HMW phthalate metabolites (MBzP, MECPP,
MEHHP, MEOHP, MEHP, MCPP) and orientation scores
among girls (n=295)(59). Another multicenter pregnancy
cohort study prospectively evaluated the inuence of prenatal
phthalate exposure on children’s behavior in the pre-school
age. They found a decreased composite score (less masculine)
in boys (n=74) was associated with increasing concentration
of MnBP, MiBP and their sum(66). In South Korea, DEHP
metabolites were signicantly associated with ADHD in 261
children aged 8-11 years. DBP metabolites were signicantly
associated with number of omission and commission errors
in continuous performance test(62). Another cross-sectional
study conducted by Cho et al. reported that full-scale IQ and
verbal IQ of school-age children (around 9 years, n=667)
were negatively associated with DEHP metabolites, espe-
cially in boys(63). A birth cohort study conducted by Kim
enrolled 460 mother-infant pairs from three South Korean
cities. They found that Mental Development Index (MDI)
was signicantly and inversely associated with the natural
logarithm levels of MEHHP (β=-0.97; 95% CI: -1.85, -0.08)
and MEOHP (β=-0.95; 95% CI: -1.87, -0.03); and Psycho-
motor Development Index (PDI) was inversely associated
with MEHHP (β=-1.20; 95% CI, -2.33, -0.08), especially in
boys(64). No signicant linear association was observed for
girls.
In the United States, Whyatt et al. found that Child PDI
scores decreased with increasing loge MnBP (β adj.=-2.81,
95% CI: -4.63, -1.0) and loge MiBP (β adj.=-2.28, 95% CI:
-3.90, -0.67); odds of motor delay increased signicantly (OR
adj.)=1.64 (95% CI: 1.10, 2.44) and 1.82 (95% CI: 1.24, 2.66
per loge MnBP and loge MiBP). MDI scores decreased with
increasing loge MnBP (β=-2.67, 95% CI: -4.70, -0.65) only
in girls; the child sex difference in odds of mental delay was
signicant. The OR’s for clinically withdrawn behavior were
2.23 (95% CI: 1.27, 3.92) and 1.57 (95% CI: 1.07, 2.31) per
Table 5. epidemiological studies on phthalates exposure and obesity.
Country/ Subjects Exposure/ Biomarkers Results References
USA/
1,451 adult male (>18
years) from NHANES
1999-2002
Urine/
MEP, MBP, MBzP,
MEHP, MEHHP,
MEOHP
MBP, MBzP, MEP:  HOMA↑
MBzP, MEP, MEHHP, MEOHP:  waist circumference↑
Stahults 2007(57)
USA/
4,369 adults (>20 years)
and some adolescent
girls from NHANES
1999-2002
Urine/
MBzP, MEHP
Phthalate metabolites:  BMI↑; waist circumference↑(in males)
MBzP:  BMI↑(in males aged 20-59)
MEHP:  BMI↑, waist circumference↑(in female aged 12-59
years old)
Hatch 2010 (58)
Abbreviations: BMI—body mass index; HOMA— homeostatic model assessment; MBP— mono-butyl phthalate; MBzP— mono-benzyl
phthalate; MEP— mono-ethyl phthalate; MEHP— mono-2-ethylhexyl phthalate; MEHHP— mono-(2-ethyl-5-hydroxyhexyl) phthalate;
MEOHP— mono-(2-ethyl-5-oxohexyl) phthalate.

Journal of Food and Drug Analysis, Vol. 20, No. 4, 2012
726
THE 20TH ANNIVERSARY ISSUE
loge unit increase in MnBP and MBzP, respectively; for clini-
cally internalizing behaviors, the OR was 1.43 (95% CI: 1.01,
1.90) per loge unit increase in MBzP. They found signicant
child sex differences in associations between MnBP and
MBzP and behaviors in internalizing domains (p<0.05)(60).
In Mexico, Téllez-Rojo et al. found that an increase in
loge concentrations of MEHP and MBzP was associated with
lower MDI scores in girls (n=25) at 36 months of life after
adjustment for potential confounders. However, they found
no statistically signicant association between MDI and
prenatal phthalate metabolites levels among boys (n=20).
They suggested a gender differential effect of prenatal phthal-
ates exposure in relation to children’s neurodevelopment(61).
The results from most of presented studies indicated possible
linkage between phthalate exposure and cognitive function in
toddler and young children. Prenatal and postnatal phthalate
exposure may inversely associate with child’s neurodevel-
opment. It is necessary to evaluate the neurological effects
of other exposure, such as lead, mercury and manganese in
future studies
VII. Infertility (Female: Gynecological Diseases; Male:
Semen Quality)
(I) Female Gynecological Diseases
Endometriosis, adenomyosis and leiomyomas are
common gynecologic disorders presented by prolonged or
heavy menstrual bleeding, pelvic pain and infertility. The
prevalence of endometriosis has been reported to be 2-22%
in women of childbearing age, whereas adenomyosis and
leiomyomas have a prevalence of 20-35% in the infertility
clinic and 20-25% in premenopausal women(67-69). Previous
studies have revealed that some extensively used phthalates,
like DEHP, are possibly associated with endometriosis(70-72).
Table 7.1 showed summarized results of epidemiological
studies on phthalates exposure and female infertility. In Italy,
Cobellis et al. showed that endometriotic women (n=55) had
signicantly higher plasma DEHP levels than controls (n=24)
and 92.6% of them had detectable DEHP or MEHP in the
peritoneal uid(70). However, another study with a smaller
sample size reported that women with uterine bromatosis
(n=15) had signicantly lower MEHP levels than controls
(n=20)(73). In India, some studies reported that women with
endometriosis had signicantly higher DnBP, BBzP, DEHP,
dimethyl phthalate (DMP), DEP and di-n-octal phthalate
(DnOP) levels than controls and these exposure levels
Table 6. Epidemiological studies on phthalates exposure and children’s neurodevelopment
Country/ Subjects Exposure/ Biomarkers Results References
USA/
295 children and pregnant
women
Urine/
MMP, MEP, MnBP,
MiBP, MBzP, MECPP,
MEHHP, MEOHP,
MEHP, MCPP
High-MWP metabolites:  Orientation score↓; Alertness
score↓;  Neurodevelopment↓(p=0.02).
High-MWP metabolites:  Neurodevelopment↓
Engel 2009(59)
USA/
74 boys and 71 girls
(3.6-6.4 years of age)
Urine/
MEHHP, MEOHP,
MnBP, MiBP
MEHHP, MEOHP, MnBP, MiBP:  masculine score↓(In
boys).
Swan 2010(66)
South Korea/
261 children, age: 8-11
years
Urine/
MEHP, MEHHP,
MEOHP
MEHP, MEHHP, MEOHP:  ADHD scores↓Kim 2009(62)
South Korea/
667 children at nine elemen-
tary schools in five South
Korean cities
Urine/
MEHP, MEOHP,
MnBP
MEHP, MEOHP, MnBP:  WISC vocabulary score↓(In boys) Cho 2010(63)
South Korea/
460 mother–infant pairs
(2006 and 2009)
Urine/
MEHHP, MEOHP,
MnBP
MEHHP, MEOHP:  MDI scores↓(β=-0.97, -0.95)
MEHHP:  PDI scores↓(β=-1.20)
MEHHP, MEOHP, MnBP: MDI↓(in males, β=-0.93~ -1.57)
MEHHP, MEOHP, MnBP:  PDI↓(in males, β=-1.25~ -2.36)
Kim 2011(64)
USA/
319 pregnant women
Urine/
MBzP, MiBP, MnBP
MiBP, MnBP:  PDI scores↓ (βadj.=-2.81; -2.28)
MnBP:  MDI scores↓(in girls, β=-2.67)
MnBP, MBzP:  clinically withdrawn behavior (β=2.23; 1.57)
MBzP:  clinically internalizing behaviors(β=1.43)
Whyatt 2012(60)
Mexico/
45 children (20 boys and 25
girls); age: 36 months
Urine/
MEHP, MBzP
MEHP, MBzP:  MDI scores↓(β=-5.53; -5.11, in girls) Téllez-Rojo, 2011(61)
Abbreviations: CI— confident interval; MBP— mono-butyl phthalate; MBzP— mono-benzyl phthalate; MCPP— mono-(3-carboxypropyl)
phthalate; MDI—mental developmental index; MEP—mono-ethyl phthalate; MECPP—mono- (2-ethyl-5-carboxypentyl) phthalate; MEHP—
mono-2-ethylhexyl phthalate; MEHHP— mono-(2-ethyl-5-hydroxyhexyl) phthalate; MEOHP— mono-(2-ethyl-5-oxohexyl) phthalate; MiBP—
mono-i-butyl phthalate; MMP— mono-methyl phthalate; MnBP: mono-n-butyl phthalate; OR— odds ratio; PDI— psychomotor development
index.

Journal of Food and Drug Analysis, Vol. 20, No. 4, 2012
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THE 20TH ANNIVERSARY ISSUE
was strongly correlated with the severity of endometriosis,
and gene polymorphism of glutathiones S-transferase M1
(GSTM1) might be a risk factor for endometriosis(71,72,74,75).
In Japan, Itoh et al. neither found signicant association
between endometriosis (n=57) and ve phthalate metabolites
(MEHP, MEOHP, MEHHP, MnBP, and MEP) nor positive
trend between phthalate exposure and severity of endome-
triosis(76). In Taiwan, Huang et al. showed that patients with
leiomyoma (n=36) had signicantly higher levels of sum
DEHP metabolites (MEHP, MEHHP and MEOHP) than
controls (n=29), whereas those with endometriosis (n=28) had
an increased level of MnBP. They further found that subjects
who carried the GSTM1 null type with a high urinary level
of sum DEHP metabolites showed a signicantly increased
risk for adenomyosis (OR=10.4, 95% CI: 1.26-85.0) and
leiomyomas (OR=5.93, 95% CI: 1.10-31.9) after adjustment
for age(77). In the United States, Weuve et al. found positive
association for MBP and inverse association for MEHP in
relation to endometriosis and leiomyoma, respectively, from
NHANES 1999-2004(78). Several case-control and cross-
sectional studies have provided a possible linkage between
phthalates exposure and female infertility. A long-term and
large-scale prospective study of girls exposed in utero to
phthalates would be needed to answer whether maternal
exposure to phthalates had bearings on estrogen regulation
and epi-genetic change in the offspring.
(II) Male Semen Quality
Experimental studies have reported that phthalates can
adversely affect sperm quality in rodents and increasing
epidemiological studies have revealed reproductive effects,
including sperm activity and spermatogenesis, of phthalates
on male infertility (Table 7.2). In the United States, Duty et
Table 7.1. Epidemiological studies on phthalates exposure and female gynecological diseases
Country/ Subjects Exposure/ Biomarkers Results References
Italy/
55 Endometriosis, 24 age-
matched control women.
Plasma/
DEHP
DEHP concentrations:  Endometriotic women ↑ Cobellis 2003(70)
India/
49 infertile women with endo-
metriosis,
38 control group I; 21 control
group II.
Plasma/
DnBP, BBP, DEHP,
DnOP
DnBP, BBP, DnOP, DEHP: Endometriosis women↑
DnBP, BBP, DnOP, DEHP:  Endometriosis↑(r=0.44~0.78)
Reddy 2006a(71)
Italy/
15 uterine fibromatosis,
20 control
Serum/
DEHP, MEHP
MEHP: Fibromatosis group↓ (p<0.01)
DEHP: Fibromatosis group↓ (p<0.01)
Luisi 2006(73)
India/
97 endometriosis
102 control
Blood /
DnBP, BBP, DEHP,
DnOP
DnBP, BBP, DnOP, DEHP: Endometriosis group＞control group
GSTM1 deletion: endometriosis↑(OR=2.12, 95% CI:1.045-
4.314, p=0.03)
Roya 2009(75)
India/
99 endometriosis; 135 control
Serum/
DMP, DEP, DnBP,
BBP, DEHP
DMP, DEP, DnBP, BBP, DEHP: Endometriosis group↑(p<0.001)
DMP, DnBP, BBP, DEHP:  Endometriosis↑(r=0.33~0.89)
Roya 2008(74)
Japan/
137 endometriosis: 80 control
(Stages0-1);
57 case (Stages2-4)
Urine/
MEP, MnBP, MBzP,
MEHP, MEHHP,
MEOHP
No significant association between endometriosis and any urinary
reatinine-adjusted phthalate metabolites was found.
ORadjusted for higher dichotomized MEHP by endometriosis was
1.57 (95% CI: 0.74-3.30).
No monotonic trend was found in urinary concentration of
phthalate metabolites by endometriosis stage (p=0.23-0.90).
Itoh 2009(76)
Taiwan/
28 endometriosis,
16 adenomyosis,
36 leiomyomas,
29 controls
Urine/
MnBP, MEHP,
ΣMEHP ( MEHP+
MEHOP+ MEHHP)
ΣMEHP: Leiomyomas women↑(p<0.05)
MnBP: Endometriosis women↑ (p<0.05)
ΣMEHP:  Adenomyosis, Leiomyoma↑(OR=10.4; 5.93)
Huang 2010(77)
USA/
1,227 women self-reported
history of endometriosis
and uterine leiomyomata
(NHANES).
Urine/
MBP, MEHP
MBP:  endometriosis, leiomyomata↑(OR=1.36, 1.56)
MEHP:  endometriosis, leiomyomata↓(OR=0.44, 0.63)
Weuve 2010(78)
Abbreviations: BBP— butyl benzyl phthalate; CI— confident interval; DEP— di-ethyl phthalate: DEHP— di-(2-ethylhexyl) phthalate; DMP—
di-methyl phthalate; DnBP— di-n-butyl phthalate; DnOP— di-n-octyl phthalate; GSTM1— Glutathione S-transferase M1; MBP— mono-butyl
phthalate; MBzP— mono-benzyl phthalate; MEP— mono-ethyl phthalate; MEHP— mono-2-ethylhexyl phthalate; MEHHP— mono-(2-ethyl-
5-hydroxyhexyl) phthalate; MEOHP— mono-(2-ethyl-5-oxohexyl) phthalate; MnBP— mono-n-butyl phthalate; ORs— odds ratio.

Journal of Food and Drug Analysis, Vol. 20, No. 4, 2012
728
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al. showed an inverse dose-response relationship between
two phthalate metabolites (MBP, MBzP) and sperm activity
(sperm concentration and motility) from 168 subfertile
couples in Boston(79). His team further enlarged a smaller
study of 463 infertile men and extended to the Great Lakes
Region including 45 infertile men(80). They further showed
that an interquartile range (IQR) change in MBzP expo-
sure was signicantly associated with a 10% decrease in
FSH concentration and that MBP exposure was borderline-
signicantly associated with a 4.8% increase in inhibin B(81).
Mendiola et al. recruited 425 male adults to evaluate the
effects of 11 phthalate exposure on reproductive hormones.
They found that total testosterone, calculated free testosterone
and the free androgen index (FAI) were inversely correlated
with the urinary levels of four DEHP metabolites. Only FAI
was signicantly associated with the urinary concentrations
of several DEHP metabolites, after adjustment by appropriate
covariates. Besides, sex hormone binding globulin (SHBG)
was positively related to the urinary concentration of MEHP
after adjustment(82).
In India, semen DEHP metabolites’ level in infertile men
was negatively correlated with sperm concentration, motility
and percentage (%) of abnormal sperm(83). In Sweden,
Jonsson et al. (2005) showed that young men (n=234) within
the highest quartile of MEP had fewer motile sperms, more
immotile sperms, and lower LH values(84). In China, there
was a signicant positive association between liqueed time
of semen and phthalate (DEP, DBP, DEHP) concentrations
of semen, whereas there was no signicant relation between
phthalate concentrations and sperm density and livability(85).
A total of 150 participants (125 men and 25 women) were
recruited from couples seeking fertility assessment from
the Reproduction Department of the Chongqing Institute of
Science and Technology for Population and Family Planning
(CISTPF)(86). They reported average concentrations for
MMP, MEP, MBP, MBzP, MEHP and MEOHP were 41.3,
300, 41.0, 0.78, 2.99 and 3.90 μg/g creatinine, respectively,
in these subjects. They found a borderline-signicant dose–
response relationship between MBP and sperm concentra-
tion, with ORs of 1.0, 6.8 and 12.0 for increasing exposure
tertiles (p=0.05), after adjustment. A positive correlation
between MEP and straight-line velocity of sperm motion was
observed without statistical signicance.
Results of several studies of subfertile men demonstrated
associations between phthalate levels and impaired sperm
quality (i.e. sperm concentration, morphology, motility),
but most in the infertility male adults. In addition, long term
prospective studies of in utero exposure to phthalates in boys
would be needed to answer whether maternal exposure to
phthalates had bearings on semen quality in the offspring.
DISCUSSION
Results of the reviewed studies indicated that phthalates
exposure may affect reproductive hormones(25-27) and devel-
opmental outcomes(33-37), thyroid hormones(38-41), pregnancy
outcomes(8,42,43,93,94), precocious puberty(45-50), neurode-
velopment(59-64,66), male infertility(79-86,95-98) and female
gynecological diseases(70,71,73-78) (Figure 3). At least one
of phthalates metabolites were associated with above health
outcomes in reviewed studies. Exposure to DEHP metabo-
lites (MEHP, MEHHP, MEOHP) was negatively associated
with free testosterone(25,26,82), ano-genital distance(34,37),
gestational age(8), thyroid function (T4, T3, TBG)(39-41),
IGF-I(41), children’ neurodevelopment(59), ADHD(62), DNA
damage(97) and sperm quality (concentration, motility,
morphology) (80,83,96,98). On the other hand, exposure to
Figure 3. Summarized endocrinal effects of phthalates exposure in human studies.
Figure 3. Summarized endocrinal effects of phthalates exposure in human studies.
Phthalates
Androgenic
Effects
Estrogenic
Effects
Thyroid
Activity
Neuron
Cognitive
Function
↓AGD
↓Testosterone
↓Sperm quality
↓Free androgen
index (FAI)
↑DNA damage
↑Premature
↑Ratio of LH
↓fT/E2
↑Sex hormone
binding globin
↑Endometriosis
↑Leiomyoma
↓FT3,T3
↓FT4,T4
↓TBG
↑TSH
↓MDI
↓PDI
↓Masculine
scores
Obesity
↑HOMA
↑Waist
circumference
↓IGF-1
Phthalates
Androgenic
Effects
Estrogenic
Effects
Thyroid
Activity
Neuron
Cognitive
Function
↓AGD
↓Testosterone
↓Sperm quality
↓Free androgen
index (FAI)
↑DNA damage
↑Premature
↑Ratio of LH
↓fT/E2
↑Sex hormone
binding globin
↑Endometriosis
↑Leiomyoma
↓FT3,T3
↓FT4,T4
↓TBG
↑TSH
↓MDI
↓PDI
↓Masculine
scores
Obesity
↑HOMA
↑Waist
circumference
↓IGF-1

Journal of Food and Drug Analysis, Vol. 20, No. 4, 2012
729
THE 20TH ANNIVERSARY ISSUE
DEHP metabolites was positively associated with precocious
puberty(45-47), size of uterus and ovarian(46), waist circumfer-
ence(57,58), female gynecological diseases (endometriosis and
leiomyoma) (70,71,74,77,78). Other phthalates metabolites (MEP
and MBP) were also positively correlated with SHBG(26) and
ratio of LH(26) and impacted on T4(38), FT4(38), T3(41), FT3(41),
Table 7.2. Epidemiological studies on phthalates exposure and male infertility
Country/Subjects Exposure/
Biomarkers Results References
USA/
168 men (subfertile)
from the hospital
Urine/
MEP
MEP:  comet extent↑ (3.6 μm, 95% CI: 0.74-6.47, p=0.015)
MEP:  TDM↑ (1.2 μm, borderline significance)
MBP, MBzP, MMP and MEHP were not significantly associated with any
comet assay parameters.
Duty 2003(79)
USA/
168 men (subfertile)
from the hospital
Urine/
MBP, MBzP
MBP_ tertile:  Sperm motility↑(OR: 1.0, 1.8, 3.0; p=0.02) ;
 Sperm concentration↑(OR:1.0, 1.4, 3.3; p=0.07)
MBzP_ tertile:  sperm concentration↑ (OR:1.0, 1.4, 5.5; p=0.02)
Duty 2003(95)
USA/
295 male (subfertile)
from the hospital
Urine/
MBP, MBzP
MBzP:  FSH concentration↓(10%, p=0.003)
MBP:  inhibin B↑(4.8%, p=0.07)
Duty 2005(81)
Sweden/
234 young Swedish men
Urine/
MEP
MEP:  Sperm motility↓; LH values↓ Jönsson 2005(84)
USA/
463 subfertile male
Urine/
MBP, MBzP
MBP, MBzP:  Sperm concentration↓
MBP:  Sperm motility↓
Hauser 2006(96)
China/
52 men (23- 48 years)
Semen/
DEP, DBP, DEHP
DEP, DBP, DEHP:  Liquefied time of semen (r=0.456,0.475, 0.457,
p=0.01)
There was no significant difference between phthalate concentrations of
semen and sperm density or livability.
Zhang 2006(85)
USA/
463 men (subfertile) the
hospital.
Urine/
MEHP
MEHP:  DNA damage↑
MEHP:  Comet extent↑(17.3%);  TDM↑(14.3%);  Tail%
↑(17.5%)
Hauser 2007(97)
USA/
45 subfertile men
Urine/
MEP, MCPP,
ΣDEHP
MEP:  Sperm concentration↓(OR=6.5, p=0.05)
MCPP:  Low morphology↓(OR=7.6, p=0.05)
ΣDEHP:  Sperm concentration↓(OR=5.4, p=0.05)
MEP:  Low morphology↓(OR=3.4, p<0.05)
Wirth 2008(80)
India/
Healthy human males
(21–40 years)
Semen/
DEP, DEHP, DBP
DEP, DBP, DEHP:  Sperm concentration↓ (p<0.05)
(r=-0.19, -0.20, -0. 25)
DBP, DEHP:  Sperm motility↓ (p<0.05) (r=-0.18)
DEHP:  Abnormal sperm↑; Depolarized mitochondria↑; LPO↑
(p<0.05) (r=0.18, 0.23, 0.20)
DBP, DEHP:  DFI↓(r=0.18, 0.20; p<0.05)
DBP, DEHP:  ROS↓(r=0.19, 0.20; p<0.05)
Pant 2008(83)
USA/
425 men (with a
pregnant women)
Urine/
MEHP, MEHHP,
MEOHP, MECPP
MEHP, MEHHP, MEOHP, MECPP:  FAI↓(p<0.05)
(r=-0.23, -0.14, -0.15, -0.12)
MEHP, MEHHP, MEOHP, MECPP:  FT↓ (p<0.01)
(r=-0.15, -0.13, -0.14, -0.13)
MEOHP, MECPP:  TT↓(r=-0.10, -0.10; p<0.05)
MEHP:  FAI/ LH ratio↓(r=-0.13; p<0.01)
MEHP:  SHBG↑(r=0.14, p<0.01)
Mendiola 2011(82)
China/
125 men and 25 women
Urine/
MEP, MBP
MBP_ tertile:  Sperm concentration↑(ORs:1.0, 6.8, 12.0; p=0.05)
MEP:  Sperm motion (VSL)↑(r=0.232, p=0.05)
Liu 2011(86)
Taiwan/
45 male workers (PVC
pellet plants)
Air/
DEHP
DEHP:  Sperm DNA denaturation (αT) ↑; DFI↑ (β=0.038; 0.140,
p<0.05)
DEHP:  Sperm motility ↓(β=−0.227, p<0.05)
Hsu 2011(98)
Abbreviations: CI— confident interval; DBP— di-butyl phthalate; DEP— di-ethyl phthalate ; DEHP— di-(2-ethylhexyl) phthalate; DFI—DNA
fragmentation index; FAI— free androgen index; FSH—follicule stimulating hormone; FT— free testosterone; IQR— interquartile range; LH—
luteinizing hormone; LPO— lipid peroxidation; MBP— monol-butyl phthalate; MBzP— mono-benzyl phthalate ; MCPP— mono-(3-carboxy-
propyl) phthalate; MEP— mono-ethyl phthalate; MECPP— mono-2-ethyl-5-carboxypentyl) phthalate; MEHP— mono-2-ethylhexyl phthalate;
MEHHP— mono-(2-ethyl-5-hydroxyhexyl) phthalate; MEOHP— mono-(2-ethyl-5-oxohexyl) phthalate; ORs— odds ratio; PVC—polyvi-
nylchloride; ROS— reactive oxygen species; SHBG— sex hormone binding globin; αT —sperm DNA denaturation; TDM— tail distributed
moment; TT— testosterone; VSL— straight-line velocity

Journal of Food and Drug Analysis, Vol. 20, No. 4, 2012
730
THE 20TH ANNIVERSARY ISSUE
AGD(33,35,36), semen quality(86), DNA damage(79,84,95,98) and
children’s neurodevelopment(59,60,64,66).
Results of the reviewed studies were all adjusted for impor-
tant confounders by adequate statistical method. In studies
of phthalates exposure and reproductive outcomes(25-27,33-37)
were adjusted for: birth weight and gender of newborns or
infants, gestational age, race, maternal education, BMI and
smoking during pregnancy. In thyroid studies(38-41): age,
BMI, gestational age, race, gender, smoking status, TBG.
In pregnancy studies(8,42,43,93,94): gender of newborns, birth
order, gestational age, maternal BMI, maternal age, maternal
smoking status. Results of studies on children’s neurode-
velopment(59-64,66) were adjusted for: age, gender of child,
maternal education, mother’s IQ and socioeconomic status.
Results of studies on semen quality(79-86,95-98) were adjusted
for: age, BMI, smoking status whereas in female gyneco-
logical diseases(70,71,73-78) on age, BMI, race, GSTM1, age at
menarche, current pregnancy and breastfeeding status.
Exposure assessment of phthalates plays an impor-
tant role of most of epidemiological studies. As phthalates
are metabolized to their metabolites within a few hours or
days(87,88), urinary phthalate metabolites are considered
good biomarkers for assessing phthalate exposure in humans
because of their low contamination rate in the laboratory
and reliability for indicating an individual’s phthalate expo-
sure(88,89). Some studies(89-91) showed good reliabilities, spec-
ies and representative of one single spot urine for prediction
of individual’s phthalate exposure over 3 - 6 months. Some
studies(8,45,46,49) assessed human phthalates exposure in cord
blood, plasma and serum. However, using serum or plasma
sample may not be the best exposure assessment of phthalate
because of laboratory contamination(14) and rapid metabo-
lization to their metabolites(88). For evaluation of critical
points of prenatal phthalate exposure, amniotic uid sample
could be better than cord blood(8,36).
Most of the reviewed studies were cross-sectional or
case-control design to assess the phthalates exposure and
health impact of human. However, the interpretations of
these results may boundary due to some limitations, such as
uncertainty of causal relationship, selection and recall bias.
Therefore, there is a need to conduct large-scale longitudinal
studies in the future . Such studies should have sufcient
sample size, representative populations and also collect the
inuence of confounding factors.
CONCLUSIONS
In reviewing of current epidemiological studies, we
suggest that phthalates may alter reproductive and sex
hormones, thyroid function, development and neurodevelop-
ment. Although more and large-scale epidemiological studies
are needed to clarify their association, reducing the phthalate
exposure in pregnant women, newborns and children is neces-
sary to prevent unexpected consequences of reproductive and
neurodevelopment effects in our offspring.
ACKNOWLEDGMENTS
We are grateful for the nancial support from National
Health Research Institutes (grants no.: EO-100-PP05,
EO-101-PP05) and Taiwan National Science Council
(NSC98-2314-B-400-001-MY3, NSC100-3114-Y-043-005).
Competing nancial interests: The authors have no
nancial interests.
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