Antidepressants and menstruation disorders in women: a cross-sectional study in three centers

Structural insights into the unexpected agonism of tetracyclic antidepressants at serotonin receptors 5-HT1eR and 5-HT1FR

Serotonin [5-hydroxytryptamine (5-HT)] acts via 13 different receptors in humans. Of these receptor subtypes, all but 5-HT1eR have confirmed roles in native tissue and are validated drug targets. Despite 5-HT1eR's therapeutic potential and plausible druggability, the mechanisms of its activation remain elusive. To illuminate 5-HT1eR's pharmacology in relation to the highly homologous 5-HT1FR, we screened a library of aminergic receptor ligands at both receptors and observe 5-HT1eR/5-HT1FR agonism by multicyclic drugs described as pan-antagonists at 5-HT receptors. Potent agonism by tetracyclic antidepressants mianserin, setiptiline, and mirtazapine suggests a mechanism for their clinically observed antimigraine properties. Using cryo-EM and mutagenesis studies, we uncover and characterize unique agonist-like binding poses of mianserin and setiptiline at 5-HT1eR distinct from similar drug scaffolds in inactive-state 5-HTR structures. Together with computational studies, our data suggest that these binding poses alongside receptor-specific allosteric coupling in 5-HT1eR and 5-HT1FR contribute to the agonist activity of these antidepressants.

Structural Insights into the Unexpected Agonism of Tetracyclic Antidepressants at Serotonin Receptors 5-HT1eR and 5-HT1FR

Serotonin (5-hydroxytryptamine, 5-HT) acts via 13 different receptors in humans. Of these receptor subtypes, all but 5-HT1eR have confirmed roles in native tissue and are validated drug targets. Despite 5-HT1eR's therapeutic potential and plausible druggability, the mechanisms of its activation remain elusive. To illuminate 5-HT1eR's pharmacology in relation to the highly homologous 5-HT1FR, we screened a library of aminergic receptor ligands at both receptors and observe 5-HT1e/1FR agonism by multicyclic drugs described as pan-antagonists at 5-HT receptors. Potent agonism by tetracyclic antidepressants mianserin, setiptiline, and mirtazapine suggests a mechanism for their clinically observed anti-migraine properties. Using cryoEM and mutagenesis studies, we uncover and characterize unique agonist-like binding poses of mianserin and setiptiline at 5-HT1eR distinct from similar drug scaffolds in inactive-state 5-HTR structures. Together with computational studies, our data suggest that these binding poses alongside receptor-specific allosteric coupling in 5-HT1eR and 5-HT1FR contribute to the agonist activity of these antidepressants.

SARS-CoV-2 infection and female reproductive health: A narrative review

The COVID-19 pandemic has had a profound global impact, affecting people's physical and mental health, and their social and economic circumstances. Mitigation measures have disproportionately affected women. Studies have reported menstrual cycle and psychological disturbance associated with the pandemic. Pregnancy is a risk factor for severe COVID-19 disease. Reports have also demonstrated associations between COVID-19 infection, vaccination and Long COVID syndrome and reproductive health disturbance. However, studies are limited and there may be significant geographical variation. Also there is bias amongst published studies, and menstrual cycle data was not included in COVID-19 and vaccine trials. Longitudinal population based studies are required. In this review we discuss existing data, along with recommendations for further research required in this area. We also discuss a pragmatic approach to women presenting with reproductive health disturbance in the era of the pandemic, encompassing a multi-system assessment of psychological, reproductive health and lifestyle.

Recent advances in understanding adverse effects associated with drugs targeting the serotonin receptor, 5-HT GPCR

It has been acknowledged that more women suffer from adverse effects of drugs than men globally. A group of drugs targeting serotonin [5-hydroxytryptamine] (5-HT) binding G-protein-coupled receptors (GPCRs) have been reported to preferentially affect women more than men, causing adverse effects such as breast cancer and infertility. 5-HT GPCR-targeted drugs in the central nervous system (CNS) manage psychiatric conditions, such as depression or bipolar and in the peripheral nervous system (PNS) treat migraines. Physiological characteristics such as specific types of hormones, higher body fat density and smaller body mass in women result in disparities in pharmacodynamics of drugs, thus explaining sex-related differences in the observed adverse effects. In this review, we discuss the side effects of drugs targeting 5-HT GPCRs based on serotonin's roles in the CNS and PNS. We have systematically reviewed adverse effects of drugs targeting 5-HT GPCR using information from the Food and Drug Administration and European Medicines Agency. Further information on drug side effects and receptor targets was acquired from the SIDER and DrugBank databases, respectively. These drugs bind to 5-HT GPCRs in the CNS, namely the brain, and PNS such as breasts, ovaries and testes, potentially causing side effects within these areas. Oestrogen affects both the biosynthesis of 5-HT and the densities of 5-HT GPCRs in given tissues and cells. 5-HT GPCR-targeting drugs perturb this process. This is likely a reason why women are experiencing more adverse effects than men due to their periodic increase and the relatively high concentrations of oestrogen in women and, thus a greater incidence of the oestrogen-mediated 5-HT system interference. In addition, women have a lower concentration of serotonin relative to men and also have a relatively faster rate of serotonin metabolism which might be contributing to the former. We discuss potential approaches that could mitigate at least some of the adverse effects experienced by women taking the 5-HT GPCR-targeting drugs.

Abnormal Uterine Bleed in a Postmenopausal Woman With the Use of Escitalopram

Selective serotonin reuptake inhibitors (SSRIs) are among the most widely used antidepressants worldwide. They are an effective first-line treatment for depression. Common side effects can be quickly remediated by switching to a different drug, making it easy to miss rare side effects and even causing them to go underreported. This case study examines an instance of uterine bleeding in a postmenopausal woman after starting an antidepressant. A detailed history determined that the medication was the only noticeable change in her daily routine before the onset of bleeding, making it the likely cause. Due to the high index of suspicion, the medication was discontinued, and it was apparent that the bleeding ceased. This phenomenon demonstrated the role of serotonin in potentiating the coagulation cascade. Research on this topic is limited, but there have been other reported cases of similar findings in the past.

Vortioxetine-Induced Amenorrhea: A Case Report

BACKGROUND

Vortioxetine is a novel multimodal antidepressant for the treatment of major depressive disorders and is widely used in clinical practice. Vortioxetine has a safe profile. However, there are case reports of other adverse effects in the literature. In this article, a case of amenorrhea due to vortioxetine is presented.

CASE

The patient is 36 years old, married, female, and is an anesthesiologist. She applied to the psychiatric outpatient clinic with symptoms of major depression. Vortioxetine was initiated at 10 mg/d and then gradually increased to 20 mg/d. She had regular menstruation until now. However, she did not menstruate after taking vortioxetine. The patient used vortioxetine for 3 months and never had a period. Pregnancy test and other tests to investigate organic etiology were normal. Two weeks after discontinuation of vortioxetine, the patient had a menstrual period.

CONCLUSIONS

Further research is needed on the relationship and possible mechanisms between vortioxetine and amenorrhea.

Depression and Its Effect on the Menstrual Cycle

A strong association is noted between depression and early perimenopause as well as menopause. The association was found to be the greatest in women with natural menopause at the age less than 40 years. Excessive corticotropin-releasing hormone (CRH) levels in depression lead to inhibition of the hypothalamic-pituitary-gonadal (HPG) axis and increased cortisol levels which further inhibits the action of gonadotropin-releasing hormone (GnRH) neurons, gonadotrophs, and gonads. The resulting changes in luteinizing hormone (LH) amplitude, follicle-stimulating hormone (FSH) levels, and LH pulse frequency were noted in patients with depression.

Besides depression, earlier surgical menopause is associated with cognitive decline. In addition, it is seen that menopausal changes predisposed females to an increased risk of depression. The association between dysmenorrhea and depression was found to be bidirectional and congruent in most studies. Patients with dysmenorrhea and coexisting depression had enhanced pain perception along with a poor response to pain relief measures. Even the treatment of underlying depression has been shown to cause menorrhagia. On the other hand, amenorrhea has also been reported as a side effect of sertraline and electroconvulsive therapy. Menstrual disorders contribute to a significant number of outpatient gynecological visits per year in the United States. Co-existing or history of depression can either be the cause of or interfere in the treatment of these disorders. Furthermore, the treatment of depression can be the etiology of various menstrual abnormalities, while menstrual disorders themselves could be the cause of depression. The increasing prevalence of depression, women’s health, multiple female-specific subtypes, and the preexisting burden of menstrual disorders necessitates more detailed studies on the effects of depression on the menstrual cycle. 

Sertraline-Related Amenorrhea in an Adolescent

Amenorrhea is one of the clinical consequences of hyperprolactinemia. Although symptomatic hyperprolactinemia is among the well-described adverse reactions of antipsychotic agents, it may also be reported with the use of selective serotonin reuptake inhibitors. Hereby, we present a case of sertraline-related hyperprolactinemic amenorrhea in an adolescent. Amenorrhea occurred 2 months after starting sertraline, and menstrual cycle restored after stopping the treatment.

Cigarette smoking is associated with an altered vaginal tract metabolomic profile

Cigarette smoking has been associated with both the diagnosis of bacterial vaginosis (BV) and a vaginal microbiota lacking protective Lactobacillus spp. As the mechanism linking smoking with vaginal microbiota and BV is unclear, we sought to compare the vaginal metabolomes of smokers and non-smokers (17 smokers/19 non-smokers). Metabolomic profiles were determined by gas and liquid chromatography mass spectrometry in a cross-sectional study. Analysis of the 16S rRNA gene populations revealed samples clustered into three community state types (CSTs) ---- CST-I (L. crispatus-dominated), CST-III (L. iners-dominated) or CST-IV (low-Lactobacillus). We identified 607 metabolites, including 12 that differed significantly (q-value < 0.05) between smokers and non-smokers. Nicotine, and the breakdown metabolites cotinine and hydroxycotinine were substantially higher in smokers, as expected. Among women categorized to CST-IV, biogenic amines, including agmatine, cadaverine, putrescine, tryptamine and tyramine were substantially higher in smokers, while dipeptides were lower in smokers. These biogenic amines are known to affect the virulence of infective pathogens and contribute to vaginal malodor. Our data suggest that cigarette smoking is associated with differences in important vaginal metabolites, and women who smoke, and particularly women who are also depauperate for Lactobacillus spp., may have increased susceptibilities to urogenital infections and increased malodor.

Identification and management of eating disorders in gynecology: menstrual health as an underutilized screening tool

Eating disorders are life-threatening conditions that disproportionately affect females, often during child-bearing years. Although the endocrinological and reproductive sequelae of these conditions often fall within the treatment purview of obstetrician-gynecologists, the assessment of eating pathology is challenging and often not part of routine clinical care. This commentary focuses on one of the common presenting symptoms of eating disorders in women, menstrual dysfunction, and discusses considerations for its clinical management in gynecology. Assessment of menstrual status provides a natural starting point for provider-patient discussion of disordered eating and weight behavior. Routine screening for eating disorders is critical and must be universal given the serious long-term consequences of these disorders.

Serotonin Reuptake Inhibitors and Risk of Abnormal Bleeding

Serotonin reuptake inhibitors (SRIs) increase the risk of abnormal bleeding by lowering platelet serotonin and hence the efficiency of platelet-driven hemostasis; by increasing gastric acidity and possibly gastric ulceration; and by other mechanisms. The upper gastrointestinal tract is the commonest site of SRI-related abnormal bleeding; bleeding at this location may be increased by concurrent nonsteroidal anti-inflammatory drug therapy and by treatment with antiplatelet or anticoagulant drugs. Bleeding at this location may be reduced by concurrent administration of acid-suppressing drugs.

Crocin, the main active saffron constituent, as an adjunctive treatment in major depressive disorder: a randomized, double-blind, placebo-controlled, pilot clinical trial

OBJECTIVE

Herbal remedies play an important role in treatment of psychiatric disorders. The aim of this study was to assess the efficacy of crocin, the main active constituent of saffron, as an adjunctive treatment in major depressive disorder (MDD).

METHOD

This study was a randomized, double-blind, placebo-controlled, pilot clinical trial. It was carried out during 4 weeks in two groups (placebo and treatment) on 40 MDD patients between 24 and 50 years old in Ibn-e-Sina psychiatric hospital, Mashhad, Iran, from March 2013 to December 2013. The crocin group (n=20) was given one selective serotonin reuptake inhibitor (SSRI) drug (fluoxetine 20mg/day or sertraline 50mg/day or citalopram 20mg/day) plus crocin tablets (30mg/day; 15mg BID) and placebo group (n=20) was administered one SSRI (fluoxetine 20mg/day or sertraline 50mg/day or citalopram 20mg/day) plus placebo (two placebo tablets per day) for 4 weeks. Both groups filled beck depression inventory (BDI), beck anxiety inventory (BAI), general health questionnaire (GHQ), the mood disorder questionnaire (MDQ), side effect evaluation questionnaire, and demographic questionnaire before and after one month intervention.

RESULTS

The crocin group showed significantly improved scores on BDI, BAI and GHQ compared to placebo group (Pvalue<0.0001). The averages of decrease in BDI, BAI and GHQ scores in placebo group were 6.15, 2.6 and 10.3 respectively, whereas the values in crocin group were 17.6, 12.7 and 17.2 after 4 weeks trial.

LIMITATIONS

Poor patient compliance with medications and short trial period, small sample size and self-report assessments were the major limitations of this study.

CONCLUSION

These results demonstrated the effect of crocin in depression and could be administered in treatment of MDD patients.