Changes in MAO activity during estrogen treatment of females with endogenous depression

Correlation between serum testosterone levels and peripartal mood states

BACKGROUND

We conducted a prospective study at the Department of Obstetrics and Gynecology, University Hospital of Vienna to investigate associations between serum testosterone levels and maternal peripartal mood states.

METHODS

Two hundred and fifty-two pregnant women at term (38 to 40 weeks' gestation) took part in the study. Blood samples for plasma testosterone levels and other biochemicals were obtained prepartum, and on the 1st and 3rd day postpartum. Mood was assessed with the McNair Profile of Mood States (POMS) at term pregnancy and daily from the first day after delivery until discharge from the hospital.

RESULTS

The final study population consisted of 193 women. Serum testosterone levels correlated significantly with maternal depression scores, both pre- and post partum (at term r=0.148, p=0.04; 1st day postpartum r=0.156, p=0.03; and 2nd day postpartum r=0.186, p=0.02, respectively). Testosterone concentrations also correlated with anger prepartum (r=0.164, p=0.02) and on the third day after delivery (r=0.188, p=0.02). No significant correlation between testosterone concentration and fatigue and vigor both pre- and post partum, respectively were found.

CONCLUSION

Serum testosterone levels correlate with depression and anger in the first postpartum days.

Imidazoline and alpha(2a)-adrenoceptor binding sites in postmenopausal women before and after estrogen replacement therapy

BACKGROUND

Platelet alpha(2A)-adrenoceptors (alpha(2A)AR) and imidazoline binding sites (subtype I(1)) have been proposed as peripheral markers of brain stem receptors that mediate sympathetic outflow and are reported to be elevated in major depression.

METHODS

In our study, p[(125)I]-iodoclonidine was used to assess platelet alpha(2A)AR and I(1) binding sites in healthy postmenopausal women (n = 34) compared with healthy women of reproductive age (n = 26). Receptor determinations were repeated in 19 postmenopausal women following 59-60 days of estrogen replacement therapy (ERT; 0.1 mg estradiol transdermal patches).

RESULTS

I(1) binding sites were twofold higher in platelets of postmenopausal women compared with women of reproduction age but were down-regulated (normalized) after 59-60 days of ERT. All other binding parameters, including platelet alpha(2A)AR density, were not different between groups nor were they changed after ERT. Platelet I(1) densities after 59-60 days of ERT were positively correlated with plasma luteinizing hormone concentrations.

CONCLUSIONS

It is suggested that increased imidazoline binding sites might be associated with mood and behavioral changes in postmenopausal women.

Women's issues in mood disorders

Since the introduction of antidepressants in the 1950s, it was assumed for the next several decades that there were no special reasons to look at the application of these medications to women. In the past half-century, particularly in the past decade, since the advent of the selective serotonin re-uptake inhibitors (SSRI), a series of specific foci have developed. Firstly, there appear to be differences in the degree of response to particular antidepressants between the genders. Secondly, there is data concerning hormonal effects of particular relevance to women, i.e. prolactin, which separates out among the antidepressants. Also of concern to women are the potential teratogenic effects of these medications, which impact on their use during pregnancy. Finally, there are certain diagnostic syndromes that are particularly relevant to women: premenstrual dysphoric disorder (PMDD); postpartum depression (PPD) and perimenopausal depression (PMD). It appears that the SSRIs may be more effective, relative to the older tricyclic antidepressants (TCA), in women than in men. The SSRIs have shown to be effective in treating these disorders, with the possibility of intermittent luteal phase treatment of PMDD. Non-antidepressant (AD) approaches have generally been found to be less effective. In the first trimester of pregnancy, there is data available supporting the safe use of SSRIs, particularly those first released, i.e. fluoxetine and sertraline. Finally, all SSRIs, with the exception of sertraline, can increase the risk of hyperprolactinaemia. This can lead to a variety of complications including amenorrhea and osteoporosis. This effect of sertraline, due to its unique profile in blocking re-uptake of dopamine, extends itself into additional relative benefits for sleep and memory. The issues associated for women with bipolar disorder are dealt with in terms of both increased risk of relapse during pregnancy and postpartum periods, as well as the relative risk of use of lithium and mood stabilizers in pregnancy and lactation.

Factors associated with early menopause

OBJECTIVE

An understanding of why certain factors contribute to a more rapid decline in ovarian function may, for some women, help prevent premature loss of fecundity and the subsequent impact of health problems secondary to long-term estrogen deficiency such as osteoporosis, cardiovascular disease, and possibly Alzheimer's disease.

METHODS

A summary of the evidence regarding factors that have been proposed to contribute to an early onset of natural menopause is presented. These factors include cigarette smoking, race, education, parity, menstrual cycle length, the use of oral contraceptives, age at menarche, major depression, anthropometry, and handedness.

RESULTS

Cigarette smoking has been found to hasten the onset of menopause by as much as one year. Lifetime number of ovulatory cycles (indicative of oocyte depletion) is also predictive of the age at natural menopause (ANP). This is consistent with the many studies that have reported early ANP among women with shorter menstrual cycles, and a later ANP among multigravid women or those who used oral contraceptives. The relationship between depressive disorder and ovarian failure is complex, involving consideration of the pharmacological effects of treatment, and is currently unclear. The findings regarding an effect of body mass index on ANP are also mixed. At this time, there is little persuasive evidence that handedness or demographic characteristics (independent of their relationship with behavioral factors like smoking) influence the ANP to any substantial degree.

CONCLUSIONS

Some factors that could potentially influence ANP have been identified, but these and other avenues of investigation warrant further study.

Estrogen, serotonin, and mood disturbance: where is the therapeutic bridge?

A growing body of literature describes the effects of estrogen and other gonadal steroids on the central nervous system. The ability of estrogen to modulate serotonergic function, in particular, raises the possibility that sex steroids may play a role in the mechanisms associated with depression and its treatment. This review will focus on those aspects of the estrogen-serotonin interaction that relate to possible increased vulnerability to affective disorders and on hormonal treatments that may be clinically applicable to women. After a discussion of the potential relationship between estrogen and mood disorders across the female life cycle, a model is proposed in which differential sensitivity to mood disorders explains the differential response by some women to periods of normal hormonal changes. Possible serotonin receptor-mediated and intracellular mechanisms by which estrogen may exert its effects on mood are also reviewed. These are compared to putative mechanisms of standard antidepressant effect. Lastly, treatment studies in which estrogen has been used as 1) monotherapy for depression, 2) an augmentation strategy, or 3) a prophylactic intervention against recurrence of depression are reviewed.

Sex steroid control of mood, mental state and memory

1. Sex steroid hormones exert profound effects on mood and mental state. Thus, in women, oestrogen is thought to protect against depression and delay the onset of schizophrenia and Alzheimer's disease. 2. Our studies in the female rat show that oestradiol, in its positive feedback mode for gonadotrophin release, increases the expression of genes for the 5-hydroxytryptamine 5-HT2A receptor and the serotonin transporter (SERT) in the dorsal raphe nucleus and the density of 5-HT2A receptor and SERT sites in regions of the forebrain that, in the human, are concerned with cognition, mental state, emotion and memory. 3. In the male rat, castration decreases while oestrogen and testosterone, but not 5 alpha-dihydrotestosterone (5 alpha-DHT), increase the density of 5-HT2A receptors in forebrain. The fact that 5 alpha-DHT has no effect suggests that the action of testosterone depends on its conversion to oestradiol by aromatase. 4. In intact rats, the density of 5-HT2A receptors in cerebral cortex is significantly higher in pro-oestrous female than in male and dioestrous female rats, showing that the spontaneous, preovulatory surge of oestradiol that reaches a peak at 12.00 h of pro-oestrus also increases the density of 5-HT2A receptors in cortex. 5. Oestrogen and testosterone (by way of its conversion to oestrogen) also stimulate the expression of the arginine vasopressin gene in the bed nucleus of the stria terminalis of the rodent, a mechanism that plays a key role in olfactory memory. 6. These actions of sex steroid hormones are discussed in the context of genomic versus non-genomic mechanisms, the recent discovery that there are two oestradiol receptors with different distributions in brain, the significance of our findings for our understanding of the control of mood, mental state and memory and the mechanism by which oestrogen stimulation of the 5-HT2A receptor could delay the onset of Alzheimer's disease.

Psychoneuroendocrinology of depression. Hypothalamic-pituitary-gonadal axis

Women are more susceptible than men to depression, particularly during periods of rapid fluctuation of gonadal hormones, such as premenstrually, postpartum, and during the climacteric. This review summarizes the evidence for the association of depression with abnormalities in reproductive hormones. Although there are similarities in stress hormones changes between depressed women and women with stress-related amenorrhea, no abnormalities in LH activity have been documented in depression. Similarly no abnormalities in LH, estradiol, or progesterone have been documented in premenstrual syndrome (PMS), although complete elimination of monthly cycling with leuprolide improves mood. Some studies have suggested beneficial effects of estrogen on mood in postmenopausal women but as yet there have been no adequately controlled studies of estrogen treatment of either premenopausal or postmenopausal women.

Mood disorders and menopause

Studies of depressive symptoms in menopausal women indicate that menopause is not associated with increased rates of depression, although mild mood and anxiety symptoms may occur in the few years prior to menopause. Women with previous affective disorders that are cyclic or that are associated with reproductive events may be at increased risk for depression at menopause. Because women presenting to menopause clinics are more likely to have affective disorders, the efficacy of estrogen for enhancing mood is an important question. Although some researchers suggest that estrogens have proven mood-elevating and antidepressant properties, others caution that the psychologic benefits of HRT deserve more systematic study before conclusions can be made. It has been suggested that minor psychologic symptoms at menopause or psychologic symptoms accompanied by vasomotor symptoms warrant a trial of HRT before considering psychotropic medication. If the psychologic symptoms do not respond to HRT, are not accompanied by vasomotor symptoms, or are clinically severe, antidepressant medication should be considered first or in addition to HRT. The psychologic effects of progesterone and androgens are less extensively studied than those of estrogen, and further research is needed.

Individual differences in changes in mood and platelet monoamine oxidase (MAO) activity during hormonal replacement therapy in menopausal women

Estrogen replacement treatment in menopausal women has been reported to have a positive effect on mood states. However, the addition of a progestin partially negates this positive effect in some women. The opposite effects of estrogen and progestin on mood may relate to their opposite effects on adrenergic and serotonergic neural function. In a double-blind, placebo-controlled, crossover study, 38 nondepressed menopausal women were cyclically treated with estrogen and estrogen plus progestin, or with placebo, for five 28-day cycles. This paper identifies the pretreatment attributes of women who do and do not have negative mood responses to progestin, and examines the relationship of these adverse side-effects to platelet monoamine oxidase (MAO), a marker of adrenergic and serotonergic functioning. Adverse mood responses to progestin occur in women with a long duration of menopause, low pretreatment serum estradiol and testosterone levels, high pretreatment serum FSH levels, low pretreatment platelet MAO activity, and pretreatment mood abnormalities. We conclude that adverse mood response to the addition of a progestin occurs in menopausal women who have low pretreatment gonadal hormone levels secondary to a long duration of menopause. Impaired central nervous system adrenergic and serotonergic functioning also may be a factor predisposing to a negative mood response to progestin.

Hypothalamic-pituitary-gonadal axis in depressed premenopausal women: elevated blood testosterone concentrations compared to normal controls

To assess the function of the hypothalamic-pituitary-gonadal (HPG) axis in major depression, a multihormonal study was carried out in 20 depressed premenopausal women. Serum concentrations of LH, FSH, estradiol, progesterone, testosterone, and GnRH-stimulated LH and FSH were measured before initiation of treatment (on the first day after menstruation) and during clomipramine treatment (same time one menstrual cycle later). Significantly higher blood concentrations of testosterone were found in untreated patients compared to normal controls. Furthermore, there was a significant negative correlation between Hamilton depression scores and estradiol concentrations of patients. The efficacy of clomipramine treatment was not related to hormonal parameters.

Schizophrenia and oestrogens--is there an association?

Some early psychiatrists already believed that schizophrenic disorders were associated with a disturbed balance of sexual hormones. This belief was based on the observation of a. an "insufficient functioning of the sexual glands" with so-called "hypoestrogenism", and b. an influence of ovarian function on schizophrenic psychoses. As this review shows, there are findings from recent research which seem to confirm that estrogens may have a protective effect in schizophrenia. There are also occasional hints at a possible "hypoestrogenism" in schizophrenia. In our own epidemiological, clinical and animal studies the hypothesis of a protective effect of oestrogens was for the first time systematically examined and confirmed. Oestrogens seem to modulate the sensitivity of D2-receptors in the brain, and clinically they seem to have a neuroleptic-like effect. These findings may have important implications for the prevention and therapy of schizophrenic disorders. Furthermore, our findings indicate the need to reinvestigate the question of a disturbed balance of sexual hormones in schizophrenic disorders. Further research on the role of oestrogens in schizophrenic disorders could in our opinion contribute to understanding the still unclear, possibly aetiologically heterogeneous pathogenetic mechanism of schizophrenic psychoses.

Double-blind randomized crossover trial of luteal phase estrogens (Premarin) in the premenstrual syndrome (PMS)

Eleven patients with moderate to severe premenstrual syndrome were given Premarin during the latter half of the menstrual cycle for at least two cycles, and a placebo for at least two cycles. Mental and physical symptoms were monitored daily with a self-rating scale. Premarin was significantly less effective than placebo in relieving the severity of both mental (p less than 0.02) and physical (p less than 0.02) symptoms of PMS (combined data p less than 0.01). It is concluded that luteal phase Premarin is ineffective as a treatment for PMS, and may actually aggravate the symptoms.

Psychoneuroendocrine research in depression. I. Hormone levels of different neuroendocrine axes and the dexamethasone suppression test

Psychoneuroendocrinology is of major importance in the biological research of depression. Most studies have focussed on the regulation of the hypothalamic-pituitary-adrenal (HPA) axis but other endocrine systems such as the hypothalamic-pituitary-thyroid (HPT), hypothalamic-pituitary-somatotropic (HPS), and the hypothalamic-pituitary-gonadal (HPG) axis have also been shown to be involved in the psychobiology of depression. There are close interrelations between various endocrine axes which possibly are affected during depressive illness. A variety of neuroendocrine abnormalities has been detected in depressive disorder but the pathophysiology of these derangements remains still unclear. Although the currently used neuroendocrine tests are not of diagnostic validity they may help to clarify the pathophysiological significance of the complex regulatory mechanisms of different neuroendocrine axes in affective disorders. Neuroendocrine regulation is determined both by peripheral and central mechanisms which both have to be adequately considered as well as potent interactions between various endocrine systems in further neuroendocrine depression research.