A new trend among many in the health and fitness community has emerged, this one is related to the handling of receipts, and many people now refuse to go near a receipt with claims such as “they give you estrogen!”.

When talking about the potential dangerous health effects of paper receipts what we are really talking about is exposure to the potentially dangerous chemical Bisphenol A (BPA) (Ehrlrich et al, 2014). BPA is a monomer originally created in 1890 as a synthetic form of estrogen, but nowadays it is used in many consumer products. BPA has been found to bind to estrogen receptors and have estrogenic effects, although BPA has low affinity to nuclear estrogen receptors relative to estradiol. BPA also acts as an antiestrogen by blocking estrogen receptors, and as an antiandrogen by blocking androgen receptors. BPA can bind to thyroid receptors and block or activate it. It appears it doesn’t take much for BPA to have effects on hormone levels in the body, with urinary concentration as low as 0.45μg/L having significant effects.

Those exposed to BPA have been shown to have significantly lower follicle stimulating hormone (FSH) and estradiol levels, they also experience higher testosterone, androstenedione, DHEAS, inhibin and SHBG levels. Although other well structured studies contradict this or show no effect on BPA concentration and certain hormones whatsoever. It is clear however that BPA exposure does negatively effect hormone balance in the body, a strong relationship between BPA concentration and polycystic ovary syndrome in women is a clear indicator of this. BPA may increase testosterone concentration through inhibiting tyrosine hydroxylase activity and stimulating testosterone production directly, however, it is hypothesised that the inverse relationship is true with testosterone reducing the concentration of liver enzymes responsible for BPA metabolism, contrastingly, another study looking at children in areas of where drinking water was contaminated with BPA found significantly reduced estradiol and testosterone levels in these children (Tang et al, 2012).

A link between BPA increases from modern day living and infertility as well as low estradiol levels has been made in women. A strong link has also been created between high BPA exposure and decreased sexual function in males. Men who was found to have a urinary BPA concentration of 38.7μg/L had a significantly reduced sperm count and a greater amount of abnormal sperm, although this level of BPA concentration will likely only occur in those who work with large amounts of this chemical (Li et al, 2011). Furthermore, a strong relationship between BPA exposure in parents and sons with a shorter anogenital distance before and after puberty also exists, which is an indicator of poor reproductive health (Marsee et al, 2006). 

Braun et al (2009) discovered that prenatal BPA exposure in girls significantly increased aggression, hyperactivity, anxious and depressed behaviour, and decreased emotional control over the 3 year period from birth which the study analysed, interestingly, only prenatal BPA exposure appeared to have an effect on neurodevelopment and also BPA exposure appeared to cause no effect on neurodevelopment during the prenatal period or in the first 3 years of life for boys. Contrastingly other findings discovered boys exposed to BPA in the prenatal period experience significantly reduced emotional control, while the effect on girls was non significant (Perera er al, 2012). A strong relationship between children with composite fillings containing BPA and poorer memory and general poorer behaviour and intelligence, as well as increased anxious and depressed behaviour has been made, even when comparing to other children with non composite fillings (Bellinger et al, 2008). Fascinatingly children with even greater degraded composite fillings experienced even greater negative psychological effects. It is unclear if it is the BPA in the fillings causing such effects however or perhaps another chemical (Maserejian et al, 2012). Realistically, the literature on BPA exposure and neurodevelopment is unclear although it does lean to the fact that BPA does cause negative alterations in the neurodevelopment of children, especially in the prenatal phase or when exposed in large amounts.

BPA has also links to increased spleen size, a strong indicator of inflammation (Tarantino et al, 2012). This creates concerns surrounding BPA exposure and cancer risk however, there is evidence suggesting no relationship between BPA levels and breast cancer (Yang et al, 2009). Other evidence even suggests that BPA and endometrial cancer may even have an inverse relationship (Hiroi et al, 2004). Contrastingly there has been strong evidence suggesting a relationship between BPA exposure and type 2 diabetes (Lang et al, 2008) and cardiovascular disease (Melzer et al, 2006).

Ehrlrich et al (2014) conducted a cross over study where 12 participants handled printed paper receipts for 2 hours per day. Baseline urinary BPA concentration was 2.1μg/L at baseline, 6.0μg/L after 2 hours, 11.1μg/L after 8 hours, 10.5μg/L after 12 hours, and 4.7μg/L after 24 hours. It is clear from these findings that paper receipts do increase levels of BPA in the body, but only after unrealistic amounts of time handling the receipts which would likely only occur in those working with receipts and still, other regular activities and events likely contribute to a greater increase in BPA levels in the body, for instance consuming canned soup has been shown to increase urinary BPA concentration to 20.8μg/L (Carwile et al, 2011), similar findings likely occur in other canned foods and beverages (Hartle et al, 2016), as well as other consumer products, including plastics, PVC, food packaging, dental sealants and household dust (JR rochester, 2013). Thankfully for those who are forced to handle receipts for a long period of time the use of nitrile gloves has been shown to block BPA from entering the body.

In conclusion BPA exposure has been shown to increase the risk of infertility in men and women, decrease sexual function in males, increase type 2 diabetes and cardiovascular disease risk and the strongest evidence suggests a disruption in the neurodevelopment of children. A significant confounding factor in the vast majority of studies looking at BPA exposure is that they are not controlled for other lifestyle factors that likely disrupt the findings, also in this article I only mention the evidence suggesting a relationship between BPA exposure and certain negative health effects, but there is much more literature on BPA exposure which show no negative health effects. I still believe that BPA exposure is likely harmful to a small degree, although in modern society it is almost impossible to avoid BPA exposure, and even small amounts of exposure which likely occurs in the majority of the population living in urban areas may be enough to cause negative health effects, with greater exposure causing potentially even greater side effects. The current evidence has caused the FDA to list BPA as a “chemical of concern” and ban it’s use in baby bottles and sippy cups. I do not believe that the movement of avoiding paper receipts to be ineffective, and unfortunately it is hard to draw any realistic practical implications from the literature which can be used to avoid BPA exposure in modern society.