rs2234693 — ESR1 PvuII

The Estrogen Receptor Alpha PvuII Polymorphism — Estrogen Sensitivity and Bone Health

The ESR1 gene encodes estrogen receptor alpha (ERα), one of two primary mediators through which estrogen exerts its effects on bone, cardiovascular, and reproductive tissues. This intron 1 variant (also called PvuII or -397T>C) lies 397 base pairs upstream of exon 2¹¹ 397 base pairs upstream of exon 2
located in a regulatory region that may affect transcription factor binding and has been extensively studied for associations with bone density, fracture risk, cardiovascular disease, and hormone therapy response²² extensively studied for associations with bone density, fracture risk, cardiovascular disease, and hormone therapy response
over 255 publications have examined this variant.

The Mechanism

The PvuII polymorphism involves a T to C transition in intron 1 that may affect transcription factor binding, potentially altering protein expression of the ESR1 gene . While the variant does not change the amino acid sequence, its location in a regulatory element suggests it influences how much estrogen receptor alpha is produced or how efficiently it responds to estrogen signaling.

The variant is on the plus strand, with T as the reference allele and C as the alternate .

The Evidence

The evidence for this variant's effects has been mixed and context-dependent. A large European meta-analysis of 18,917 individuals³³ A large European meta-analysis of 18,917 individuals
Ioannidis et al., JAMA 2004 found that none of the ESR1 polymorphisms including PvuII had any statistically significant effect on bone mineral density, yet significant reductions in fracture risk were observed . This suggests

ESR1 determines fracture risk by mechanisms independent of BMD .

More recent findings are nuanced by ancestry.

A meta-analysis revealed that the PvuII T allele is a highly significant risk factor for hip fracture susceptibility, with an effect magnitude similar in male and pre-menopausal and post-menopausal female patients . However, when credibility was evaluated applying false-positive reporting probability and Bayesian criteria, significant associations were considered as false positive results , suggesting the need for cautious interpretation.

For muscle health, the C allele provides protection against muscle injury by lowering muscle stiffness in a study of 1,311 Japanese top-level athletes⁴⁴ study of 1,311 Japanese top-level athletes
Kumagai et al., Medicine & Science in Sports & Exercise 2019.

Cardiovascular associations remain controversial.

A large Danish study found ESR1 IVS1-397T/C polymorphism does not influence HDL cholesterol response to hormone replacement therapy or risk of cardiovascular disease . Yet when combined with the XbaI variant (rs9340799), haplotype analysis revealed that C-G haplotype confers approximately 5-fold risk and T-A haplotype adds 1.4-fold risk towards coronary artery disease .

Practical Implications

The most actionable finding relates to hormone therapy response. A study of 343 Slovak postmenopausal women⁵⁵ A study of 343 Slovak postmenopausal women
Mondockova et al., BMC Medical Genetics 2018 found that

TT genotype responded more poorly to hormone therapy and raloxifene in lumbar spine BMD compared to TC and CC genotypes . This suggests women with the TT genotype may need closer monitoring or higher doses of estrogen-based therapies.

For fracture risk, the evidence suggests TT individuals should prioritize bone health through weight-bearing exercise, adequate calcium and vitamin D intake, and regular bone density screening, particularly after menopause when estrogen levels decline naturally.

Interactions

This variant is commonly studied alongside the XbaI variant (rs9340799), also in ESR1 intron 1. The two SNPs are in linkage disequilibrium and often analyzed as haplotypes. Studies show the combined effect differs from either variant alone, particularly for cardiovascular disease risk where the C-G haplotype (rs2234693 C paired with rs9340799 G) confers substantially higher CAD risk than would be predicted from either variant independently. Additionally, interactions with MTHFR variants (rs1801133) have been documented in cardiovascular contexts.