Estrogen action: a historic perspective on the implications of considering alternative approaches.

In the 50 years since the initial reports of a cognate estrogen receptor (ER), much has been learned about the diverse effects and mechanisms of estrogens, such as 17beta-estradiol (E(2)). This expert narrative review briefly summarizes perspectives and/or recent work of the authors, who have been addressing different aspects of estrogen action, but take a common approach of using alternative considerations to gain insight into mechanisms with clinical relevance, and inform future studies, regarding estrogen action. Their "Top Ten" favorite alternatives that are discussed herein are as follows.

Implications of the binding of tamoxifen to the coactivator recognition site of the estrogen receptor.

A number of studies have reported on the unusual pharmacological behavior of type I antiestrogens, such as tamoxifen. These agents display mixed agonist/antagonist activity in a dose-, cell-, and tissue-specific manner. Consequently, many efforts have been made to develop so-called 'pure' antiestrogens that lack mixed agonist/antagonist activity.

A second binding site for hydroxytamoxifen within the coactivator-binding groove of estrogen receptor beta.

Evidence is presented that the estrogen antagonist 4-hydroxytamoxifen (HT) can occupy not only the core binding pocket within the ligand-binding domain of estrogen receptor (ER) beta but also a second site on its surface. The crystal structure of the ligand-binding domain (LBD) associated with HT was determined to 2.2 A and revealed two molecules of HT bound to the protein.

The contribution of "alternative approaches" to understanding steroid hormone action.

In the 47 yr since the first evidence for a steroid hormone receptor was presented at an international congress to an audience of five persons, the concept of "alternative approach" has played an important role in providing new understanding. By asking not what does an estrogenic hormone do to cellular processes in responsive tissues but what do these cells do to the hormone, it was shown that rat uterus contains a characteristic protein with which the hormone associates to promote growth. In the following decade, it was established that this substance is a true receptor, involved in hormonal action.

A two-site model for antiestrogen action.

Evidence is presented for a unified model for the reaction of antiestrogens with estrogen receptors that explains much of the unusual pharmacology of these clinically important agents. Agonist activity results from occupancy of the estradiol-binding (primary) site in the receptor and antagonism from the additional interaction with a secondary locus not recognized by hormone. In the case of type I antiestrogens, such as tamoxifen, this is weaker than primary site binding, so these substances are agonists at low concentrations and antagonists at higher levels.

The estrogen receptor: a model for molecular medicine.

The identification of the estrogen receptor (ER) in the laboratory provided a mechanism to describe the target site specificity of estrogen action in uterus, vagina, pituitary gland, and breast cancer. Most importantly, a test was established to predict the outcome of antihormonal therapy in breast cancer, and a target was identified to develop new drugs for the treatment and prevention of breast cancer. The development of tamoxifen for the treatment of all stages of ER-positive breast cancers has resulted in the improved survival of breast cancer patients.