Longitudinal evaluation of reproductive function in women treated for bipolar disorder

Association among abnormal glycolipids, reproductive hormones, and cognitive dysfunction in female patients with bipolar disorder

BACKGROUND

Patients with bipolar disorder (BD) show abnormalities in glucolipid metabolism and reproductive hormone levels, which are of concern in women with BD. This study was dedicated to investigating the glucolipid and reproductive hormone levels of female patients, and to preliminarily investigating their relationships with cognition.

METHODS

A total of 58 unmedicated female BD patients, 61 stable-medicated female BD patients, and 63 healthy controls (HC) were recruited in this study. Serum glycolipid indexes and reproductive hormones were measured. Cognitive function was assessed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and the Stroop Color-Word Test (Stroop test).

RESULTS

Patients with BD showed significant cognitive impairment (p < 0.05), which was not affected by medication. Triglycerides (TG), luteinizing hormone (LH), and high-density lipoprotein cholesterol (HDL-c) were altered in stable-medicated BD patients. In addition, regression analysis showed that progesterone (PRGE) and prolactin (PRL) were negatively associated with cognitive performance in stable-medicated BD patients.

CONCLUSIONS

Female BD patients may have cognitive deficits and abnormal levels of glycolipids and reproductive hormones. And abnormal levels of glycolipids and reproductive hormones may be associated with cognitive dysfunction in female BD patients.

Changes in Psychotropic Drug Concentrations Across the Menstrual Cycle: A Pilot Study

BACKGROUND

The escalating prescription of psychopharmacological medications to women of reproductive age underscores the growing significance of sex-specific variations in pharmacotherapy. Despite this, clinical trials have largely overlooked these differences. Preliminary data indicate sex-specific variations in the neurobiology of affective disorders and in the metabolism, pharmacodynamics, and kinetics of therapeutic drugs. This underscores the imperative for a more nuanced exploration of menstrual cycle-dependent fluctuations in psychotropic drugs. This pilot study aimed to investigate drug and hormone fluctuations in female patients with affective disorders, aiming to enhance comprehension of the interplay between cycle-related hormone fluctuations and pharmacokinetics. The ultimate goal is to facilitate more effective and safer pharmacological therapy in the future.

METHODS

Blood samples were collected from 27 patients and 27 age-matched control participants at 3 distinct time points (early follicular phase, ovulation, and late luteal phase) during each menstrual cycle. Depressive and manic symptoms were assessed, and hormone concentrations were measured in the entire sample, while drug concentrations were assessed solely in the affective disorder sample using mass spectrometry.

RESULTS

Significant variations in drug concentration were observed throughout the menstrual cycle for bupropion, with a trend toward altered concentration for venlafaxine. Moreover, notable differences in hormone concentrations were identified between patients and controls, even after accounting for the impact of contraceptive use, diagnoses, and medication.

CONCLUSIONS

This pilot study reinforces previously reported data, underscoring the significance of sex-specific pharmacological therapy approaches. It provides further evidence supporting the interaction among sex hormones, drugs, and symptoms of affective disorders.

Prevalence of Heavy Menstrual Bleeding and Its Associated Cognitive Risks and Predictive Factors in Women With Severe Mental Disorders

There has been limited studies examining treatment-induced heavy menstrual bleeding (HMB) in women with severe mental illnesses. The aim of this study was to examine HMB prevalence and HMB-associated factors in young women (18–34 years old) diagnosed with bipolar disorder (BP), major depressive disorder (MDD), or schizophrenia (SCZ) who have full insight and normal intelligence. Eighteen-month menstruation histories were recorded with pictorial blood loss assessment chart assessments of HMB. Multivariate analyses were conducted to obtain odds ratios (ORs) and 95% confidence intervals (CIs). Drug effects on cognition were assessed with the MATRICS Consensus Cognitive Battery (MCCB). HMB prevalence were: BP, 25.85%; MDD, 18.78%; and SCH, 13.7%. High glycosylated hemoglobin (HbA1c) level was a strong risk factor for HMB [BP OR, 19.39 (16.60–23.01); MDD OR, 2.69 (4.59–13.78); and SCZ OR, 9.59 (6.14–12.43)]. Additional risk factors included fasting blood sugar, 2-h postprandial blood glucose, and use of the medication valproate [BP: OR, 16.00 (95%CI 12.74–20.22); MDD: OR, 13.88 (95%CI 11.24–17.03); and SCZ OR, 11.35 (95%CI 8.84–19.20)]. Antipsychotic, antidepressant, and electroconvulsive therapy use were minor risk factors. Pharmacotherapy-induced visual learning impairment was associated with HMB [BP: OR, 9.01 (95%CI 3.15–13.44); MDD: OR, 5.99 (95%CI 3.11–9.00); and SCZ: OR, 7.09 (95%CI 2.99–9.20)]. Lithium emerged as a protective factor against HMB [BP: OR, 0.22 (95%CI 0.14–0.40); MDD: OR, 0.30 (95%CI 0.20–0.62); and SCZ: OR, 0.65 (95%CI 0.33–0.90)]. In SCZ patients, hyperlipidemia and high total cholesterol were HMB-associated factors (ORs, 1.87–2.22). Psychiatrist awareness of HMB risk is concerningly low (12/257, 2.28%). In conclusion, prescription of VPA should be cautioned for women with mental illness, especially BP, and lithium may be protective against HMB.

Risk-to-befit ratios of consecutive antidepressants for heavy menstrual bleeding in young women with bipolar disorder or major depressive disorder

The occurrence of heavy menstrual bleeding (HMB) induced by pharmacological agents has been reported in young adult women. This study aimed to investigate a possible association between the occurrence rates of HMB and different treatment methods such as antidepressant agents alone and in combination with other pharmacological agents. The examined cohort included young women (age 18-35 years, n = 1,949) with bipolar disorder (BP) or major depressive disorder (MDD). Menstruation history for 24 months was recorded and evaluated according to pictorial blood loss assessment charts of HMB. Multivariate analyses were conducted to determine odds ratios (ORs) and 95% confidence intervals. The examined antidepressant agents had varying ORs for patients with BP vs. those with MDD. For example, the ORs of venlafaxine-induced HMB were 5.27 and 4.58 for patients with BP and MDD, respectively; duloxetine-induced HMB, 4.72 and 3.98; mirtazapine-induced HMB, 3.26 and 2.39; fluvoxamine-induced HMB, 3.11 and 2.08; fluoxetine-induced HMB, 2.45 and 1.13; citalopram-induced HMB, 2.03 and 1.25; escitalopram-induced HMB, 1.85 and 1.99; agomelatine-induced HMB, 1.45 and 2.97; paroxetine-induced HMB, 1.19 and 1.75; sertraline-induced HMB, 0.88 and 1.13; reboxetine-induced HMB, 0.45 and 0.45; and bupropion-induced HMB, 0.33 and 0.37, in each case. However, when antidepressant agents were combined with valproate, the OR of HMB greatly increased, with distinct profiles observed for patients with BP vs. those with MDD. For example, the ORs of HMB induced by venlafaxine combined with valproate were 8.48 and 6.70 for patients with BP and MDD, respectively; for duloxetine, 5.40 and 4.40; mirtazapine, 5.67 and 3.73; fluvoxamine, 5.27 and 3.37; fluoxetine, 3.69 and 4.30; citalopram, 5.88 and 3.46; escitalopram, 6.00 and 7.55; agomelatine, 4.26 and 5.65; paroxetine, 5.24 and 3.25; sertraline, 4.97 and 5.11; reboxetine, 3.54 and 2.19; and bupropion, 4.85 and 3.46, in each case. In conclusion, some antidepressant agents exhibited potential risks of inducing HMB. Therefore, a combined prescription of antidepressant agents and valproate should be carefully considered for young women with HMB.

Serum testosterone levels in bipolar and unipolar depressed female patients and the role of medication status

Objective: to compare testosterone levels between female depressed patients and female bipolar patients.Methods: Sixty-one female patients with major depressive disorder (MDD) (n = 23) or bipolar disorder (BD) (n = 38) between 18 and 45 years old were included in the study. Participants were evaluated during a depressive or manic episode with the Hamilton depression rating scale (HDRS) or Young mania rating scale (YMRS), respectively. No patients in the MDD group were taken valproate while in the BD group 14 (36.84%) were taken valproate. Total testosterone (TT) and free testosterone (FT) levels were quantified during the early follicular phase of the cycle, with radioimmunoassay or solid phase enzyme-linked immunoassay. Data were collected from May 2016 to February 2017.Results: Mean TT serum levels were significantly higher in BD patients in comparison to MDD patients. Although age and diagnosis were related to TT levels, however when we added valproate use in the analysis, only the relation between TT and valproate use remained significant.Conclusions: In this sample, TT levels were related to valproate use in patients with BD. More studies regarding the role of testosterone in affective symptoms should be conducted to clarify the relation between testosterone, affective disorders, and medication.KeypointsWe observed that testosterone levels were significant higher in bipolar women compared to women with MDD.The use of valproate could be associated with the testosterone levels in female patients with BD.Evaluation of women suffering BD should include a testosterone levels determination, particularly when they are taking valproate.

Sleep and Daytime Complaints During Manic and Depressive Episodes in Children and Adolescents With Bipolar Disorder

INTRODUCTION

Depressive and manic episodes of bipolar disorder can interact with sleep complaints, followed by a worsened psychiatric condition. The aim of this study was to examine the interaction of sleep disorders with bipolar disorder in youths during depressive and manic episodes.

METHODS

The target population was children and adolescents drawn from the Children and Adolescents Affective Disorder Program. Clinical assessment for current psychiatric diagnosis was done by direct clinical interview, Diagnostic Interview for Children and Adolescents (DSM-IV), and best-estimated clinical consensus. We applied sleep questionnaires from which we obtained sleep and daytime complaints during manic and depressive episodes. All statistical tests of significance were done using 2-tailed tests with α = 0.05.

RESULTS

Participants in this study comprised 29 children (age = 10 ± 3 years, boys = 23) and 43 adolescents (age = 15 ± 2.4 years, boys = 30). Sleep complaints were observed in 66.4% of participants during manic episodes and 52.3% during depressive episodes. 37.9% of patients had sleep complaints in both episodes. Time in bed was longer during depressive episodes than manic episodes (p = 0.01). We found a high prevalence of nocturnal enuresis in depressive episodes in children and adolescents, which was statistically significant compared with manic episodes (p < 0.05). Unrested sleep was higher in adolescents in both episodes, and it was statistically significant during manic episodes (p < 0.05).

CONCLUSION

According to our analyses, the minority of patients had sleep complaints in both episodes. Our data showed that nocturnal enuresis occurred more frequently during depressive than manic episodes. Further research is necessary to understand the implications of these data.

Bipolar disorder in women

This article summarizes research pertinent to the clinical care of women with bipolar disorder. With bipolar disorder, female gender correlates with more depressive symptoms and different comorbidities. There is a high risk of symptom recurrence postpartum and possibly during perimenopause. Women with bipolar disorder have increased risk of sexually transmitted diseases, unplanned pregnancies, excessive weight gain, metabolic syndrome, and cardiovascular disease. Mood stabilizing medications, specific psychotherapies, and lifestyle changes can stabilize mood and improve functioning. Pharmacologic considerations include understanding interactions between mood stabilizing medications and contraceptive agents and risks and benefits of mood stabilizing medication during pregnancy and lactation.

A four week randomised control trial of adjunctive medroxyprogesterone and tamoxifen in women with mania

Emerging research has suggested that hormone treatments such as selective oestrogen receptor modulators (SERMs) or progestins may be useful in the treatment of mania. The current pilot study compared the use of the SERM tamoxifen and the progestin medroxyprogesterone acetate (MPA), as an adjunct to mood stabiliser medications, for the treatment of mania symptoms in 51 women in a 28-day double blind, placebo controlled study. The primary outcome was the change between baseline and day 28 mania scores as measured by the Clinician Administered Rating Scale for Mania (CARS-M). Adjunctive MPA treatment provided greater and more rapid improvement in mania symptoms compared with adjunctive placebo and tamoxifen treatment. Adjunctive therapy with MPA may be a potentially useful new treatment for persistent mania, leading to a greater and more rapid resolution of symptoms compared with mood stabiliser treatment alone.

Evaluation of reproductive function in women treated for bipolar disorder compared to healthy controls

OBJECTIVES

The purpose of the present study was to investigate the reproductive function of women with bipolar disorder (BD) compared to healthy controls.

METHODS

Women diagnosed with BD and healthy controls with no psychiatric history, aged 18-45 years, were recruited from a university clinic and surrounding community. Participants completed a baseline reproductive health questionnaire, serum hormone assessment, and ovulation tracking for three consecutive cycles using urine luteinizing hormone (LH)-detecting strips with a confirmatory luteal-phase serum progesterone.

RESULTS

Women with BD (n = 103) did not differ from controls (n = 36) in demographics, rates of menstrual abnormalities (MAs), or number of ovulation-positive cycles. Of the women with BD, 17% reported a current MA and 39% reported a past MA. Dehydroepiandrosterone sulfate and 17-hydroxyprogesterone levels were higher in controls (p = 0.052 and 0.004, respectively), but there were no other differences in biochemical levels. Medication type, dose, or duration was not associated with MA or biochemical markers, although those currently taking an atypical antipsychotic agent indicated a greater rate of current or past MA (80% versus 55%, p = 0.013). In women with BD, 22% reported a period of amenorrhea associated with exercising or stress, versus 8% of controls (p = 0.064). Self-reported rates of bulimia and anorexia nervosa were 10% and 5%, respectively.

CONCLUSIONS

Rates of MA and biochemical levels did not significantly differ between women with BD and controls. Current atypical antipsychotic agent use was associated with a higher rate of current or past MA and should be further investigated. The incidence of stress-induced amenorrhea should be further investigated in this population, as should the comorbid incidence of eating disorders.

Effects of the menstrual cycle on bipolar disorder

OBJECTIVES

Several lines of research suggest that reproductive events may affect the course of bipolar disorder (BD) in some women. With respect to the menstrual cycle, the focus has been on dysphoric symptoms [e.g., premenstrual dysphoric disorder (PMDD)], and the exacerbation of depression, in the premenstrual phase. This article reviews the literature on the potential effects of the menstrual cycle on BD.

METHODS

A systematic search for published case reports and research studies available through March, 2013 was conducted. Several combinations of search terms were entered into PubMed and PsycInfo.

RESULTS

Overall, 25 case reports, ten retrospective studies, and 11 prospective studies were identified. The majority (64%) of case reports involved hypomanic or manic episodes in the premenstrual phase. Retrospective results suggest that 25-77% and 15-27% of women with BD meet the criteria for premenstrual syndrome (PMS) and PMDD, respectively. Menstrual cycle-related mood changes were reported by 64-68% of women with BD in retrospective studies, and were displayed by 44-65% of women in prospective studies.

CONCLUSIONS

Although research has focused on the premenstrual phase to the neglect of the periovulatory phase, it appears that a subgroup of women with BD, possibly those with hormonal sensitivity, experience menstrual cycle effects on depressive, hypomanic, and manic episodes. These phase-episode effects appear to be heterogeneous and may have implications for treatment. Whether they might best be described using course specifiers, similar to postpartum onset and rapid cycling, or as diagnostic entities, like PMDD, requires further study.

The clinical management of bipolar disorder: a review of evidence-based guidelines

OBJECTIVE

To discuss the criteria used to diagnose the mood episodes that constitute bipolar disorder, the approach to the differential diagnosis of these presentations, and the evidence-based treatments that are currently available.

DATA SOURCES

A search for evidence-based guidelines for the diagnosis and treatment of adults with bipolar disorder was performed on May 5, 2010, using the National Guideline Clearinghouse database, the Agency for Healthcare Research and Quality Evidence Reports database, and the Cochrane Database of Systematic Reviews. In addition, a clinical query of the PubMed database (completed March 1, 2010) and searches of drug manufacturers' Web sites (for unpublished trials) were performed to identify randomized, controlled trials and meta-analyses evaluating strategies to treat resistant depression.

STUDY SELECTION

Guidelines were selected based on data from randomized, controlled trials; meta-analyses; and well-conducted naturalistic trials that were published since 2005.

DATA EXTRACTION

Four evidence-based treatment guidelines for bipolar disorder were included. Three were published in 2009: those put forth as part of an Australian project, those of the British Association for Psychopharmacology, and those produced by the International Society for Bipolar Disorders and the Canadian Network for Mood and Anxiety Treatments. The most recent US guidelines are that of the Texas Implementation of Medication Algorithms project, last updated in 2005.

DATA SYNTHESIS

Recommendations from all 4 guidelines were reviewed and are presented with a focus on using them to improve clinical care. The recommendations with the most agreement and highest level of clinical evidence were as follows: (1) mania should be treated first-line with lithium, divalproex, or an atypical antipsychotic medication; (2) mixed episodes should be treated first-line with divalproex or an atypical antipsychotic; (3) bipolar depression should be treated with quetiapine, olanzapine/fluoxetine combination, or lamotrigine; and (4) all patients should be offered group or individual psychoeducation. Additionally, recommendations for therapeutic drug monitoring are presented due to their importance for patient safety, particularly for the primary care physician, although these are based on consensus guidelines.

CONCLUSIONS

Bipolar disorder is a lifelong illness that is complicated by high comorbidity and risk of poor health outcomes, making the primary care physician's role vital in improving patient quality of life. The management of acute mood episodes should focus first on safety, should include psychiatric consultation as soon as possible, and should begin with an evidence-based treatment that may be continued into the maintenance phase. Long-term management focuses on maintenance of euthymia, requires ongoing medication, and may benefit from adjunctive psychotherapy.

Menstrual effects on mood symptoms in treated women with bipolar disorder

OBJECTIVES

Reports suggest women with bipolar disorder (BD) have high rates of perimenstrual mood worsening. In this prospective study, the authors compared healthy controls and depressed and euthymic BD patients on medications on mood levels, psychosocial function, and physical symptoms in the late luteal versus the early follicular phase.

METHODS

At baseline, the lifetime diagnosis of bipolar I disorder or bipolar II disorder, current mood episode, and absence of premenstrual dysphoric disorder in controls were confirmed with the Structured Clinical Interview for DSM-IV Disorders. Subjects were assessed across three menstrual cycles during the late luteal and early follicular phases. Clinicians administered the Structured Interview Guide for the Hamilton Depression Rating Scale and the Mania Rating Scale to assess levels of depression and hypomania/mania, respectively. Subjects completed self-report ratings on psychosocial function and perceived stress and tracked daily mood and physical symptoms on the National Institute of Mental Health LifeChart and the Daily Rating Form. Ovulation was verified objectively with mid-cycle luteinizing hormone urine dipsticks and serum progesterone levels.

RESULTS

The sample characteristics were similar among the three patient groups of healthy controls (n = 10), BD-euthymic (n = 6), and BD-depressed (n = 5). The two-way analysis of variance indicated a significant difference among the diagnostic groups on depression scores, psychosocial functioning, and levels of perceived stress. There was no significant difference for menstrual phase or the interaction of menstrual phase by diagnostic group.

CONCLUSIONS

Mood symptom level, psychosocial functioning, perceived stress, and physical discomfort were unrelated to menstrual phase in patients with BD. Appropriate maintenance treatment may prevent menstrual related mood symptoms. Use of an objective marker of ovulation is critical for research involving menstrual related outcomes.

Polycystic ovary syndrome: etiology, pathogenesis and diagnosis

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women of reproductive age, with a prevalence of up to 10%. Various diagnostic criteria have been proposed, generally centered around the features of hyperandrogenism and/or hyperandrogenemia, oligo-ovulation and polycystic ovarian morphology. Insulin resistance is present in a majority of cases, with compensatory hyperinsulinemia contributing to hyperandrogenism via stimulation of ovarian androgen secretion and inhibition of hepatic sex hormone-binding globulin production. Adipose tissue dysfunction has been implicated as a contributor to the insulin resistance observed in PCOS. Environmental and genetic factors also have a role in the development of PCOS. The syndrome is associated with numerous morbidities, including infertility, obstetrical complications, type 2 diabetes mellitus, cardiovascular disease, and mood and eating disorders. Despite these morbidities, PCOS may be common in our society owing to evolutionary advantages of the syndrome in ancient times, including smaller family sizes, reduced exposure to childbirth-related mortality, increased muscle mass and greater capacity to store energy. The diagnosis of PCOS hinges on establishing key features while ruling out other hyperandrogenic or oligo-ovulatory disorders. Treatment is focused on the goals of ameliorating hyperandrogenic symptoms, inducing ovulation and preventing cardiometabolic complications.

Is sex important? Gender differences in bipolar disorder

Sex is clearly important in unipolar mood disorder with compelling evidence that depression is approximately twice as common in women than in men. In the case of bipolar disorder, however, it is widely perceived that the reported equal rate of illness in men and women reflects no important gender distinctions. In this paper we review the literature on gender differences in bipolar illness and attempt to summarize what is known and what requires further study. Despite the uncertainties that remain some conclusions can be drawn. Most studies, but not all, report an almost equal gender ratio in the prevalence of bipolar disorder but the majority of studies do report an increased risk in women of bipolar II/hypomania, rapid cycling and mixed episodes. Important gender distinctions are also found in patterns of co-morbidity. No consistent gender differences have been found in a number of variables including rates of depressive episodes, age and polarity of onset, symptoms, severity of the illness, response to treatment and suicidal behaviour. Unsurprisingly, however, perhaps the major distinction between men and women with bipolar disorder is the impact that reproductive life events, particularly childbirth, have on women with this diagnosis.

Incidence of polycystic ovaries and androgen serum levels in women with borderline personality disorder

Obesity, increased visceral fat and disturbed glucose metabolism have been found in borderline personality disorder (BPD) patients. These conditions are often associated with disturbed androgen metabolism. Elevated androgens in women are related to polycystic ovaries (PCO) and might have an impact on psychopathology. Thus, higher prevalence of PCO and elevated androgen levels are suspected in BPD. In the study, we examined 31 BPD patients and 30 healthy controls ultrasonographically for PCO and measured their serum levels of androgens and interacting hormones. Furthermore, influence on psychopathology of free testosterone (FT) serum level was assessed. PCO was significantly more prevalent in BPD patients (30.4%) compared to healthy controls (6.9%). Testosterone, FT, androstenedione (A), and 17alpha-hydroxyprogesterone (17-OHP) were significantly elevated in the BPD group independently of BMI. FT serum level significantly correlated with depressive symptoms. In summary, our data suggest a disturbed androgen metabolism in BPD patients.

The role of valproate in metabolic disturbances in bipolar disorder patients

BACKGROUND

Our previous report showed that patients with bipolar disorder (BD) have higher prevalence of hypertriglyceridemia, low high-density lipoprotein cholesterol (HDL) and obesity in Taiwan. To confirm whether the metabolic disturbances is associated with the disease itself or the medications used for treating BD, we further compared the metabolic status among the valproate (VPA) treated BD patients, drug-free BD patients and healthy controls in Taiwan.

METHOD

This cross-sectional study included 119 healthy controls and 77 BD patients diagnosed according to the DSMIV-TR criteria in a university hospital. Among the diseased group, 25 remitted BD patients were drug-free (BD-F), and 52 of them were treated with VPA (BD-VPA). Their body mass index (BMI), plasma glucose levels and plasma lipid profiles were measured.

RESULTS

Plasma fasting glucose, insulin, total cholesterol, triglyceride, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol (LDL) levels were significantly different among BD-VPA, the BD-F, and the healthy control groups. Valproate treatment was associated with significant higher plasma insulin, triglyceride, and BMI levels as well as lower fasting glucose and HDL levels. However, these biochemical indexes did not differ significantly between the BD-F and the healthy control groups.

CONCLUSION

These results provide further evidence that VPA treatment for BD may increase the risk of metabolic disturbances. The risk may be reduced after discontinuing VPA medication.

Reproductive and metabolic abnormalities associated with bipolar disorder and its treatment

Women with mood disorders, especially bipolar disorder (BD), have been shown to have high rates of reproductive and metabolic dysfunction. The available data on the functional, anatomic, and clinical neuroendocrine abnormalities in women with BD suggest a two-tiered relationship with mood pathology. First, many of the medications commonly used in the treatment of BD can have deleterious effects on blood levels of reproductive hormones and consequently on the hypothalamic-pituitary-gonadal (HPG) axis and reproductive function. Studies that have specifically addressed the association between psychotropic medications and menstrual abnormalities, polycystic ovary syndrome, and overall reproductive endocrine function in women with BD have found high rates of HPG irregularities in women with BD. Second, there is evidence of reproductive dysfunction in women with BD prior to treatment. In addition, many of the psychotropic medications used in the treatment of BD are associated with weight gain, insulin resistance, and dyslipidemia. These metabolic side effects further compound the neuroendocrine system dysregulation in women with BD. Current understanding of the reproductive and metabolic function in women with BD points to vulnerability, which in turn increases the risk of later-life cardiovascular disease and diabetes, among other morbidities, for women with BD.

Lithium chloride treatment induces epithelial cell proliferation in xenografted human endometrium

BACKGROUND

In mouse endometrium, glycogen synthase kinase-3beta (GSK3beta) is a key enzyme controlling nuclear localization of cyclin D1. We developed a functional model of xenografted human endometrium to test whether similar mechanisms are operative in the human by using Lithium chloride (LiCl), an inhibitor of GSK3beta.

METHODS

Human endometrial samples were obtained from normal volunteers, then implanted under the kidney capsule of nude mice, and treated with estradiol-17beta (E2) or LiCl. Xenografts were assessed for protein expression of MKI-67, mini-chromosome maintenance protein-2, estrogen receptor (ER), progesterone receptor (PR) and cyclin D1.

RESULTS

Both E2 and LiCl induced a robust proliferative response in the epithelium. Only lithium treatment produced clear nuclear localization of cyclin D1 consistent with the proliferative response observed. Regenerated endometrium had detectable ER and PR expression.

CONCLUSION

Xenografted human endometrium provides a dynamic model of uterine biology. Administration of LiCl in the absence of E2 induced epithelial proliferation, supporting the hypothesis that human and murine endometrial proliferation may share key regulatory pathways. These data suggest a possible link between the increased menstrual disturbances in women with affective disorders taking lithium and the consequent potential for the development of endometrial proliferative disorder.

Polycystic ovary syndrome in women using valproate: a review

Valproate (VPA) is a highly effective drug successfully employed in several neuropsychiatric diseases. In the last 15 years, an increased prevalence of polycystic ovary syndrome (PCOS) associated with VPA use has been reported in both women with epilepsy and women with bipolar disorders. However, data on this subject are contrasting and it is possible that different factors might play a role in the development of PCOS in these patients. The risk of developing PCOS during VPA treatment seems to be higher in women with epilepsy than in women with bipolar disorders, and this might be due to an underlying neuroendocrine dysfunction related to the seizure disorder. Gynecologists must be aware of the possibility that PCOS in these populations of patients might be related to VPA use, and a careful multi-specialist approach is required for evaluating the risks and benefits of this treatment in the presence of features of PCOS.

Pharmacological management of atypical antipsychotic-induced weight gain

Excessive bodyweight gain was reported during the 1950s as an adverse effect of typical antipsychotic drug treatment, but the magnitude of bodyweight gain was found to be higher with the atypical antipsychotic drugs that were introduced after 1990. Clozapine and olanzapine produce the greatest bodyweight gain, ziprasidone and aripiprazole have a neutral influence, and quetiapine and risperidone cause an intermediate effect. In the CATIE study, the percentage of patients with bodyweight gain of >7% compared with baseline differed significantly between the antipsychotic drugs, i.e. 30%, 16%, 14%, 12% and 7% for olanzapine, quetiapine, risperidone, perphenazine (a typical antipsychotic) and ziprasidone, respectively (p<0.001). Appetite stimulation is probably a key cause of bodyweight gain, but genetic polymorphisms modify the bodyweight response during treatment with atypical antipsychotics. In addition to nutritional advice, programmed physical activity, cognitive-behavioural training and atypical antipsychotic switching, pharmacological adjunctive treatments have been assessed to counteract excessive bodyweight gain. In some clinical trials, nizatidine, amantadine, reboxetine, topiramate, sibutramine and metformin proved effective in preventing or reversing atypical antipsychotic-induced bodyweight gain; however, the results are inconclusive since few randomized, placebo-controlled clinical trials have been conducted. Indeed, most studies were short-term trials without adequate statistical power and, in the case of metformin, nizatidine and sibutramine, the results are contradictory. The tolerability profile of these agents is adequate. More studies are needed before formal recommendations on the use of these drugs can be made. Meanwhile, clinicians are advised to use any of these adjunctive treatments according to their individual pharmacological and tolerability profiles, and the patient's personal and family history of bodyweight gain and metabolic dysfunction.

Sodium Valproate, Hyperandrogenism and Altered Ovarian Function in Indian Women with Epilepsy: A Prospective Study

PURPOSE

To assess the association of long-term sodium valproate therapy with reproductive endocrine disorders in Indian women with generalized epilepsy.

METHODS

Clinical parameters, ovarian morphology, and serum reproductive hormone concentrations were evaluated in 30 clinically normal and eumenorrheic reproductive age women with generalized epilepsy who were newly initiated on valproate. Longitudinal evaluations were done in 25 of these women after 1 year, and in some of them after 2 and 3 years of therapy.

RESULTS

Of the 25 women who completed 1 year follow-up, we observed clinically relevant weight gain in 40%, hirsutism in 20%, menstrual abnormalities in 24%, polycystic ovaries (PCO) in 16%, polycystic ovarian syndrome (PCOS) in 20%, and a significant increase in mean serum testosterone (p=0.046). A significant positive correlation existed between weight gain and the development of menstrual abnormalities (r=0.66, p<0.0001), hirsutism (r=0.53, p=0.006) and PCO (r=0.51, p=0.012). No correlation existed between weight change and serum reproductive hormonal changes. Yearly follow-up for next 2 years in some of these women revealed persistence of menstrual abnormalities, hirsutism and PCO, a significant linear increase in mean body weight, body mass index, and serum testosterone concentrations, and an increase in serum LH levels from second year onwards.

LIMITATIONS

Limitations include small sample size and a high dropout rate on follow-up.

CONCLUSIONS

Long-term valproate therapy in Indian women with generalized epilepsy is associated with development of hirsutism, significant weight gain, stable or progressive alterations in reproductive hormonal function, and ultimately a higher occurrence of PCOS.

Insulin resistance in depressive disorders and Alzheimer's disease: Revisiting the missing link hypothesis

Several lines of evidence suggest an association between depressive disorders and Alzheimer's disease (AD). We previously suggested central nervous system (CNS) effects of insulin resistance (IR) to be an important link between depressive disorders and AD. Although the exact mechanism of central IR is not known, it is thought that central IR results in inadequate glucose metabolism in the brain. According to our hypothesis, inadequate glucose utilization resulting from IR underlies neuronal changes in crucial brain regions (i.e. limbic system) observed among patients with depressive disorders, the same brain regions affected in AD. Further, in patients with undetected and/or untreated IR, such changes in glucose utilization, if unresolved, may lead to neurodegeneration. Our studies have demonstrated a high prevalence of IR in patients with depressive disorders, and reciprocally, a high prevalence of depression in patients with the primary IR disorder polycystic ovary syndrome (PCOS), and we believe these populations have significantly increased risk of cognitive decline. Herein, we review the IR link in depressive disorders and AD and describe the results of our studies and others in support of this hypothesis.