Gender-based differences and menstrual cycle-related changes in specific diseases: implications for pharmacotherapy

A Text Mining Protocol for Extracting Drug-Drug Interaction and Adverse Drug Reactions Specific to Patient Population, Pharmacokinetics, Pharmacodynamics, and Disease

Drug-drug interactions (DDIs) and adverse drug reactions (ADR) are experienced by many patients, especially by elderly population due to their multiple comorbidities and polypharmacy. Databases such as PubMed contain hundreds of abstracts with DDI and ADR information. PubMed is being updated every day with thousands of abstracts. Therefore, manually retrieving the data and extracting the relevant information is tedious task. Hence, automated text mining approaches are required to retrieve DDI and ADR information from PubMed. Recently we developed a hybrid approach for predicting DDI and ADR information from PubMed. There are many other existing approaches for retrieving DDI and ADR information from PubMed. However, none of the approaches are meant for retrieving DDI and ADR specific to patient population, gender, pharmacokinetics, and pharmacodynamics. Here, we present a text mining protocol which is based on our recent work for retrieving DDI and ADR information specific to patient population, gender, pharmacokinetics, and pharmacodynamics from PubMed.

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. 

Gender-based personalized pharmacotherapy: a systematic review

PURPOSE

In general, male and female are prescribed the same amount of dosage even if most of the cases female required less dosage than male. Physicians are often facing problem on appropriate drug dosing, efficient treatment, and drug safety for a female in general. To identify and synthesize evidence about the effectiveness of gender-based therapy; provide the information to patients, providers, and health system intervention to ensure safety treatment; and minimize adverse effects.

METHODS

We performed a systematic review to evaluate the effect of gender difference on pharmacotherapy. Published articles from January 1990 to December 2015 were identified using specific term in MEDLINE (PubMed), EMBASE, and the Cochrane library according to search strategies that strengthen the reporting of observational and clinical studies.

RESULTS

Twenty-six studies fulfilled the inclusion criteria for this systematic review, yielding a total of 6309 subjects. We observed that female generally has a lower the gastric emptying time, gastric PH, lean body mass, and higher plasma volume, BMI, body fat, as well as reduce hepatic clearance, difference in activity of Cytochrome P450 enzyme, and metabolize drugs at different rate compared with male. Other significant factors such as conjugation, protein binding, absorption, and the renal elimination could not be ignored. However, these differences can lead to adverse effects in female especially for the pregnant, post-menopausal, and elderly women.

CONCLUSION

This systematic review provides an evidence for the effectiveness of dosage difference to ensure safety and efficient treatment. Future studies on the current topic are, therefore, recommended to reduce the adverse effect of therapy.

Questions relating to premenstrual asthma

The study of asthma in fertile women needs to consider its potentially recurrent exacerbation in a specific phase of the menstrual cycle. Premenstrual asthma (PMA) refers to the deterioration of asthma in some women of fertile age during the premenstrual phase. Prevalence varies considerably according to studies (11%-47.44%) mainly because there is no standardized definition of the illness. There is a possible link between PMA and premenstrual syndrome, which is a set of physical and psychic manifestations that occur in some fertile women during the same premenstrual phase. This relation has been widely studied but there are still several unknowns. PMA etiopathogeny is not known. It involves possible causes such as hormonal variations in the premenstrual phase, the coexistence of atopy, variations during the cycle in substances related to inflammation, like LTC4 leukotrienes, catecholamines, E2 and F2α prostaglandins and certain cytokines. Also considered are psychological factors related to this phase of the menstrual cycle, a high susceptibility to infection or increased bronchial hyperreactivity prior to menstruation. Yet no factor fully explains its etiology, consequently no specific treatment exists. Researchers have investigated hormones, anti-leukotrienes, prostaglandin synthesis inhibitors, diuretics, phytoestrogens and alternative therapies, but none has been shown to be effective.

Menstrual suppression: current perspectives

Menstrual suppression to provide relief of menstrual-related symptoms or to manage medical conditions associated with menstrual morbidity or menstrual exacerbation has been used clinically since the development of steroid hormonal therapies. Options range from the extended or continuous use of combined hormonal oral contraceptives, to the use of combined hormonal patches and rings, progestins given in a variety of formulations from intramuscular injection to oral therapies to intrauterine devices, and other agents such as gonadotropin-releasing hormone (GnRH) antagonists. The agents used for menstrual suppression have variable rates of success in inducing amenorrhea, but typically have increasing rates of amenorrhea over time. Therapy may be limited by side effects, most commonly irregular, unscheduled bleeding. These therapies can benefit women’s quality of life, and by stabilizing the hormonal milieu, potentially improve the course of underlying medical conditions such as diabetes or a seizure disorder. This review addresses situations in which menstrual suppression may be of benefit, and lists options which have been successful in inducing medical amenorrhea.

Factors affecting the development of adverse drug reactions (Review article)

OBJECTIVES

To discuss the effect of certain factors on the occurrence of Adverse Drug Reactions (ADRs).

DATA SOURCES

A systematic review of the literature in the period between 1991 and 2012 was made based on PubMed, the Cochrane database of systematic reviews, EMBASE and IDIS. Key words used were: medication error, adverse drug reaction, iatrogenic disease factors, ambulatory care, primary health care, side effects and treatment hazards.

SUMMARY

Many factors play a crucial role in the occurrence of ADRs, some of these are patient related, drug related or socially related factors. Age for instance has a very critical impact on the occurrence of ADRs, both very young and very old patients are more vulnerable to these reactions than other age groups. Alcohol intake also has a crucial impact on ADRs. Other factors are gender, race, pregnancy, breast feeding, kidney problems, liver function, drug dose and frequency and many other factors. The effect of these factors on ADRs is well documented in the medical literature. Taking these factors into consideration during medical evaluation enables medical practitioners to choose the best drug regimen.

CONCLUSION

Many factors affect the occurrence of ADRs. Some of these factors can be changed like smoking or alcohol intake others cannot be changed like age, presence of other diseases or genetic factors. Understanding the different effects of these factors on ADRs enables healthcare professionals to choose the most appropriate medication for that particular patient. It also helps the healthcare professionals to give the best advice to patients. Pharmacogenomics is the most recent science which emphasizes the genetic predisposition of ADRs. This innovative science provides a new perspective in dealing with the decision making process of drug selection.

Sex-related differences in epidemiological and clinic-based headache studies

This manuscript discusses sex-related differences in headache prevalence, the symptoms and natural history of migraine, associated disability, and co-morbid disorders. The role of sex hormones is discussed with reference to the effects of hormonal events across the reproductive years and the specific effects of the menstrual cycle on migraine. Differences between the sexes were identified across all parameters reviewed. Future research should ensure that data are analyzed separately for men and women to ensure that differences between the sexes are identified.

Factors related with the higher percentage of hospitalizations due to asthma amongst women: the FRIAM study

INTRODUCTION

The reason why there is a higher hospitalization rate due to asthma exacerbations amongst women is unclear. The objective of this study is to explore the possible causes that may explain this fact.

METHODS

A multi-center, prospective study including asthma patients hospitalized in the pulmonary medicine departments during a two-year period. By means of a questionnaire, the following data were collected: demographic characteristics and treatment compliance, anxiety-depression, hyperventilation and asthma control, both prior to and during the hospitalization.

RESULTS

183 patients were included, 115 (62.84%) of whom were women. The women were older (52.4 ± 18.3/43.4 ± 18.7; P=.02), were more frequently prescribed inhaled corticosteroids (63.2%/47.1%; P=.03) and had a higher rate of hyperventilation syndrome (57.3/35.9; P=.02) and a longer mean hospital stay (7.3 ± 3.4/5.9 ± 3.6; P=.02). The percentage of smokers among the women was lower (21.2%/38.8%; p=0.01) and the FEV(1) was lower at admittance (58.2% ± 15.9/67.5% ± 17.4; P=.03). In the 40 to 60-year-old age range, an association was demonstrated between being female and the 'previous hospitalizations' variable (OR, 16.1; 95% CI, 1.6-156.7); sex and obesity were also independently associated (OR, 4.8; 95% CI, 1.06-22).

CONCLUSIONS

In this cohort, the rate of hospitalization for asthma was higher in women than in men. Being a woman between the ages of 40 and 60 is associated with previous hospitalizations and is a risk factor for asthma-related hospitalization. This situation could partially be explained by the hormonal changes during menopause, where polyposis and obesity are independent risk factors.

Hormonal link to autoimmune allergies

IgE recognition of autoantigens might augment allergic inflammation in the absence of exogenous allergen exposure. Among allergy and autoimmunity, there is disproportionate representation of males before puberty and females after puberty, suggesting a role for sex hormones. Hormone allergy is an allergic reaction where the offending allergens are one's own hormones. It is an immune reaction to the hormones, which can interfere with the normal function of the hormones. It can occur perimenstrually in women along with the variation in menstrual cycle. The perimenstrual allergies are about the cyclic abundance of the hormone causing a cyclic expression of allergic symptoms. The inflammatory mechanisms of allergic reactions to hormone allergens, which are intrinsic to the body, are the same as the mechanisms of allergic reactions to external allergens.

Premenstrual asthma and symptoms related to premenstrual syndrome

BACKGROUND

It is unclear whether premenstrual asthma is associated with premenstrual syndrome. The objective of this study is to compare premenstrual symptoms among asthmatic women according to whether they have premenstrual asthma or not.

METHODS

A questionnaire on respiratory symptoms during a single menstrual cycle was developed for asthmatics of fertile age, together with another on symptoms related to premenstrual syndrome. These included dysphoric-psychiatric symptoms (anxiety, depression, fatigue, irritability, and mood swings), edematous symptoms (abdominal and mammary tension, swelling, acne, and migraine), and other symptoms (leg pains, nausea, sweating, vomiting, and tiredness). Morning and evening peak flow scores were collected to evaluate lung function. Premenstrual asthma was determined to be a ≥ 20% objective exacerbation in the premenstrual phase over the preovulatory phase in terms of both respiratory symptoms and/or peak flow. The intensity of the change in symptoms was evaluated according to the effect size.

RESULTS

The study examined 103 patients of fertile age, 46 of whom (44.7%) presented with premenstrual asthma. Practically all of the monitored symptoms increased in the premenstrual phase with respect to the preovulatory phase. This increase was greater in women with premenstrual asthma, especially for abdominal tension (effect size .88 against .33; p = .009) and mammary tension (.95 against .49; p = .018).

CONCLUSIONS

A clear link was found between premenstrual asthma and the premenstrual exacerbation of dysphoric symptoms, and certain edematous symptoms such as abdominal and mammary tension as well as a swelling sensation.

An interdisciplinary analysis of sex and gender in relation to the pathogenesis of bronchial asthma

BACKGROUND

An increasing number of studies confirm that pathogenesis and prevalence of bronchial asthma are age and sex dependent. Detailed physiological mechanisms of the changing sex ratios with age are not fully known, however, the gender (socio-cultural) factors are also imperative. Although multiple factors definitely influence the pathogenesis of asthma, only individual or few combinations of these have been investigated.

METHODS

The terms 'sex', 'gender' and plausible combinations of both were systematically researched in selected databases (Medline, Scopus) or other sources, including publications from January 2000 to June 2007. Generated articles were categorized, either as endogenous or exogenous factors influencing the pathogenesis of asthma, and divided into the following subgroups: genetic, immunological, hormonal, gynaecological, nutritional, and environmental parameters.

RESULTS

An increasing number of studies investigate the influence of sex and gender in the aetiology, therapy and prevention of asthma. While their results are still debatable, others regarding its initiation, perpetuation and cessation have been clarified. Recent insights into interactions at biomolecular and immunological levels greatly contribute to clarifying sex-specific influences. Despite occasional oversimplifications, a trend for explanations considering the complex interplay of different factors can be observed. This work is in line with this trend and offers explanation models from our point of view.

CONCLUSIONS

Some disagreements regarding the patho-physiology, diagnosis, treatment and prevention of asthma still prevail. Nevertheless, in order to better appreciate its complexity, openness to and persistent consideration for interdisciplinary as well as sex- and gender-related factors is required of the medical-research community in future investigations.

The gender disparity in adult asthma hospitalizations dynamically relates to age

Although it is known that women have a higher prevalence of asthma than men, it is not known whether and/or how gender differences in asthma severity are affected by age. Asthma hospitalization rates were compared for men and women in New York State from 1990 through 2006 between the ages of 20 and 84. Female and male hospitalization rates were calculated and characterized for the different age intervals. The ratio between female to male hospitalization rates were compared for different age groups. While males showed an overall linear increase in hospitalization rates with increasing age, women had a steeper increase in hospitalization rates followed by a slowing beginning at the ages between 40-54. The ratio of the female to male hospitalization rates was maximal in this age interval, with a mean ratio of 2.41 compared to 1.97 in other ages. For each year, this female to male ratio was consistently higher for the age range between 40 to 54 than for other ages, and this difference remained when admissions associated obesity, tobacco dependence, and chronic non-asthmatic pulmonary disease were excluded. Differences between the hospitalization rates for men and women vary by age. The gender gap in hospitalization rates appears to be maximal between the ages of 40 and 54. This may reflect age related asthma prevalence and/or severity differences between men and women.

Gender-specific effects of cytokine gene polymorphisms on childhood vaccine responses

Cytokine gene polymorphisms affect vaccine responses and gender-specific effects are known for many phenotypes. Therefore, this study investigated gender-specific effects of cytokine gene polymorphisms on vaccine responses. In 263 2-year-old subjects selected for parental history of atopy, boys with IL-4 C-589T and IL-4Ralpha I50V genotypes associated with atopy had increased Diptheria Toxoid (DiphTox) and Tetanus Toxoid (TetTox) responses compared with the remaining alleles (IL-4 C-589T: DipTox p=0.01, TetTox p=0.04; IL-4Ralpha.I50V: DipTox p=0.04, TetTox p=0.08). Contrastingly, girls with IL-10 -592C genotypes associated with atopy had lower levels of DiphTox (p=0.03) and TetTox (p=0.02) responses compared with the remaining allele. Additionally, interaction effects were found for IL-4 C-589T (p=0.01) and IL-4Ralpha I50V (p=0.04) polymorphisms. In conclusion, these findings support the interaction of primary genetic and modifying factors on vaccine responses and the importance of atopic genetics to these responses.

A matched-cohort study of utilization outcomes for an adult medicaid population enrolled in an asthma disease management program

Few studies have examined the clinical and utilization impact of asthma disease management programs for Medicaid beneficiaries. This study examines utilization and clinical outcomes for an adult group of low- to moderate-risk patients with asthma. Propensity scores are used to construct matched samples of treated-control pairs in order to establish equivalent comparison groups and evaluate the effects of program participation. During the program period, the participants experienced 33.3% fewer hospitalizations, 42% fewer bed days, 87% fewer asthma-related admissions, fewer ED visits, and higher rates of medication usage than those for matched controls, suggesting the beneficial impact of participation for Medicaid program participants.

Gender-specific pharmacology: implications for therapy

Historically, research into drugs and diseases has assumed that beyond the reproductive system, gender differences did not exist or were not relevant. Interest in recognizing the importance of gender-based differences in pharmacology and disease has been fueled in recent years by an increasing amount of data revealing variations in drug efficacy and side effect profiles between the genders as well as differences in disease prevalence.

Neuronal excitability in the periaqueductal grey matter during the estrous cycle in female Wistar rats

Extracellular recordings were made from output neurons in the dorsal half of the periaqueductal gray matter (dPAG) in urethane-anesthetized female Wistar rats. All the neurons were quiescent. A basal level of firing was therefore induced by continuous iontophoretic application of D,L-homocysteic acid (DLH). In the presence of the GABA(A) receptor antagonist bicuculline methiodide (BIC 0-30 nA) the DLH-induced firing increased further, revealing the presence of ongoing GABAergic inhibitory tone on the recorded neurons. The BIC-induced increase in firing rate was significantly greater in neurons recorded during estrus (Est) and late diestrus (LD) compared with proestrus (Pro) and early diestrus (ED) suggesting that GABAergic tone was lower in Est and LD. I.v. injection of the panicogenic cholecystokinin (CCK)(B) receptor agonist pentagastrin (PG, 40 microg kg(-1)) produced an increase in firing rate in 12/17 (70%) of neurons tested in the dPAG. Iontophoretic application of PG (10-30 nA) also produced a current-related increase in firing rate in 73.6% of the neurons tested. The excitatory response was reduced during application of the selective CCK(B) receptor antagonist beta-[2-([2-(8-azaspiro[4.5]dec-8-ylcarbonyl)-4,6-dimethylphenyl]amino)-2-oxoethyl]-(R)-napthalenepropanoic acid (CR2945) (60 nA, n=6). The PG-evoked increase in firing rate was significantly greater in neurons recorded during Est and LD compared with during Pro and ED. Juxtacellular labeling with neurobiotin in eight neurons revealed multipolar cells 12-44 microm diameter with up to six primary dendrites. In three of eight neurons, a filled axon was present and coursed without branching toward the perimeter of the periaqueductal gray matter (PAG). The estrous cycle-related change in responsiveness to BIC and PG suggests that the panic circuitry in the PAG may become more responsive to panicogenic agents during estrus and late diestrus as a consequence of a decrease in the intrinsic level of inhibitory GABAergic tone. The findings may have implications for understanding the neural processes that underlie the development of premenstrual dysphorias in women.

Plasticity of GABAA receptor subunit expression during the oestrous cycle of the rat: implications for premenstrual syndrome in women

Many women experience psychological changes during the luteal phase of their menstrual cycle. The late luteal (premenstrual) phase, when symptoms become most severe, is characterized by declining levels of ovarian progesterone. In female rats, withdrawal from prolonged dosing with progesterone leads to upregulation of alpha4 and delta subunits of the GABAA receptor in several brain regions. During the oestrous cycle of the rat, the natural fall in progesterone that occurs in late dioestrus is associated with a parallel increase in expression of alpha4, beta1 and delta GABAA receptor subunits in neurones in the periaqueductal grey matter (PAG), suggesting that new receptors of the alpha4beta1delta composition have been formed. Recombinant alpha4beta1delta receptors display a low EC50 for GABA, which is consistent with activation by extracellular levels of GABA. They are also likely to be located extrasynaptically and to carry tonic currents. In the PAG, a region involved in mediating panic-like anxiety, alpha4, beta1 and delta GABAA receptor subunits are located principally on GABAergic interneurones. On-going GABAergic neuronal activity normally limits and controls the excitability of the panic circuitry. During late dioestrus, when expression of alpha4, beta1 and delta subunits on GABAergic interneurones is upregulated, the increase in tonic current would be expected to lead to a reduction in the activity of the GABAergic population. Thus the panic circuitry would become intrinsically more excitable. It is suggested that during the menstrual cycle in women, plasticity of GABAA receptor subunit expression in brain regions such as the PAG, which are involved in mediating anxiety behaviour, may underlie some of the changes in mood that occur during the premenstrual period.

A matched-cohort study of selected clinical and utilization outcomes for an asthma care support program

Estimating the economic and clinical impact of asthma disease management programs traditionally has relied on non-experimental designs and employed matching or stratification methods with limited success. Selecting similar comparison subjects is problematic since subjects must be compared across numerous pretreatment factors. In cases where treatment and comparison subjects differ greatly on observed characteristics, conclusions may be particularly sensitive to an incorrectly specified model used for matching. A propensity score method constructs matched samples of treated-control pairs, addresses program selection bias, and reduces bias in estimates of treatment effects. To investigate the program effects of an asthma care support program delivered to high-risk asthmatics (persons with a previous inpatient admission, emergency department [ED] visit, or observation visit), we conducted a matched-cohort study on 196 participants. Using administrative claims data and selected clinical indicators, we analyzed hospitalization, ED, and physician office visit rates to estimate effects of program enrollment. Total hospitalizations, asthma-related hospitalizations, bed days, and ED visits for participants were lower and statistically different from that of the matched-cohort group during the program period, suggesting the beneficial effects of monitoring, education, and counseling activities for participants. Where controlled randomized clinical trials cannot be performed because of ethical, cost, or feasibility issues, the use of propensity scores provides an alternative for estimating treatment effects using observational data. This study employs a propensity score-matching methodology to select a subset of comparison units most comparable to treatment units, and documents the beneficial outcomes of participation in an asthma care support program.

CXCR3 polymorphisms associated with risk of asthma

The chemokine (C-X-C motif) receptor 3 (CXCR3) gene, on chromosome Xq13, is known to have critical roles in inflammatory and immune responses. In an effort to discover polymorphisms have been implicated in asthma, we investigated the genetic polymorphisms in CXCR3 to evaluate it as a potential candidate gene for a host genetic study of asthma. Statistical analysis revealed that one SNP in intron 1, c.12+234G > A, showed significant association with the risk of asthma development (P = 0.007, OR = 0.81). By subgroup analyses stratified by gender and atopic status, the genetic effect of c.12+234G > A on asthma was more apparent among male atopic subjects (P = 0.0009, OR = 0.61). Our findings suggest that polymorphisms in CXCR3 might be one of the genetic factors for the risk of asthma development, especially in male atopic subjects. CXCR3 variation/haplotype information identified in this study will provide valuable information and insight into strategies for the control of asthma and its subgroup, atopy.

Depressive Symptoms and Insecure Attachment as Predictors of Disability in a Clinical Population of Patients With Episodic and Chronic Migraine

OBJECTIVES

To define predictors of migraine-related disability in patients with episodic and chronic migraine referred to a specialty migraine clinic, focusing on depressive symptoms and insecure attachment style that, because of their association with responses to pain and physical illness, might be predictive of greater migraine-related disability.

BACKGROUND

The Migraine Disability Assessment questionnaire (MIDAS) has proved to be a reliable and easy-to-use instrument to assess migraine-related disability. As clinicians are increasingly using MIDAS in their diagnostic and treatment decisions for patient care, an understanding of the factors influencing migraine-related disability is essential for a rationale use of such an instrument.

METHODS

Two-hundred patients suffering from episodic migraine without aura (EM), and chronic migraine (CM) with and without medication overuse, and referred to a specialty headache clinic were evaluated using the MIDAS, the Beck Depression Inventory (BDI), and the Attachment Style Questionnaire (ASQ). Diagnosis of episodic and chronic migraine was operationally defined according to the International Headache Society (IHS) and Silberstein-Lipton criteria.

RESULTS

Multiple regression analysis showed that, in the total sample, disability was higher in those patients with CM, more severe depressive symptoms, an insecure style of attachment (as reflected by a lower score on the ASQ confidence scale), and experiencing more severe headache pain intensity. In the subgroup of patients with episodic migraine, an insecure style of attachment emerged as the most significant predictor of disability (other significant predictors were female sex and number of headache days per month). In contrast, in the subgroup of patients with CM, the only significant predictor of the total MIDAS score was a greater severity of depressive symptoms.

CONCLUSIONS

Our findings demonstrate the relevance of attachment style, an enduring psychological trait not evaluated in previous studies, in influencing the disability level in patients with migraine and confirm the role of comorbid depressive symptoms in modulating the impact of migraine on every day functioning.

Changes in GABA(A) receptor subunit expression in the midbrain during the oestrous cycle in Wistar rats

In women, the late luteal phase or "premenstrual" period is commonly associated with psychological disturbances, which include mood changes and increased aggression. The underlying cause is unknown but one possibility is that fluctuations in levels of neuroactive steroids precipitate changes in expression of GABA(A) receptor subunits that result in functional changes in inhibitory control systems. The present study investigated the levels of expression of alpha4, beta1 and delta GABA(A) receptor subunits in the periaqueductal gray matter (PAG) in rats and whether plasticity occurs during the oestrous cycle in females. In male rats alpha4, beta1 and delta subunit immunoreactive neurones were present throughout the PAG in similar numbers. In female rats in proestrus, oestrus and early dioestrus, the density of alpha4, beta1 and delta subunit immunoreactive cells was similar to males. However, in late dioestrus, the numbers increased significantly, especially in the dorsolateral PAG, a region which is particularly rich in GABAergic interneurones. These parallel changes may reflect an increase in expression of the alpha4beta1delta GABA(A) receptor subtype. Recombinant alpha4beta1delta receptors, expressed in Xenopus oocytes, exhibited and EC(50) for GABA an order of magnitude lower (2.02+/-0.33 microM; mean+/-S.E.M.) than that found for the most ubiquitous alpha1beta2gamma2 GABA(A) receptor (32.8+/-2.5 microM). Increased expression of alpha4beta1delta GABA(A) receptors in the interneurones of the PAG could render the panic circuitry abnormally excitable by disinhibiting the ongoing GABAergic inhibition. Similar changes in neuronal excitability within the PAG in women consequent to falling steroid levels in the late luteal phase of the menstrual cycle could contribute to the development of pre-menstrual dysphoria.

Health-related quality of life among adolescents with allergy-like conditions - with emphasis on food hypersensitivity

BACKGROUND

It is known that there is an increase in the prevalence of allergy and that allergic diseases have a negative impact on individuals' health-related quality of life (HRQL). However, research in this field is mainly focused on individuals with verified allergy, i.e. leaving out those with self-reported allergy-like conditions but with no doctor-diagnosis. Furthermore, studies on food hypersensitivity and quality of life are scarce. In order to receive information about the extent to which adolescent females and males experience allergy-like conditions and the impact of these conditions on their everyday life, the present study aimed to investigate the magnitude of self-reported allergy-like conditions in adolescence and to evaluate their HRQL. Special focus was put on food hypersensitivity as a specific allergy-like condition and on gender differences.

METHODS

In connection with lessons completed at the children's school, a study-specific questionnaire and the generic instrument SF-36 were distributed to 1488 adolescents, 13-21 years old (response rate 97%).

RESULTS

Sixty-four per cent of the respondents reported some kind of allergy-like condition: 46% reported hypersensitivity to defined substances and 51% reported allergic diseases (i.e. asthma/wheezing, eczema/rash, rhino-conjunctivitis). A total of 19% reported food hypersensitivity. Females more often reported allergy-like conditions compared with males (p < 0.001). The adolescents with allergy-like conditions reported significantly lower HRQL (p < 0.001) in seven of the eight SF-36 health scales compared with adolescents without such conditions, regardless of whether the condition had been doctor-diagnosed or not. Most adolescents suffered from complex allergy-like conditions.

CONCLUSIONS

The results indicate a need to consider the psychosocial impact of allergy-like conditions during school age. Further research is needed to elucidate the gender differences in this area. A team approach addressing better understanding of how allergy-like conditions impair the HRQL may improve the management of the adolescent's health problems, both in health-care services and in schools.

Gender differences in treatment response to sertraline versus imipramine in patients with nonmelancholic depressive disorders

There is evidence of gender differences in depressive disorders in terms of epidemiology and clinical manifestations. However, few studies have addressed the gender differences in terms of antidepressant treatment response in clinical practice. The aim of this study was to examine gender differences in the acute antidepressant response to sertraline and imipramine in nonmelancholic depressive disorders. A total of 239 patients with nonmelancholic major depression or dysthymia (DSM-III-R) and a score of >/=18 at baseline on the Hamilton Depression Rating Scale (HAM-D) were randomised in a 1:1 ratio treatment with flexible doses of sertraline (50-200 mg/day) or imipramine (75-225 mg/day) for 8 weeks in a multicenter, randomised, open-labeled, parallel group comparative trial. Depressive and anxiety symptoms were assessed using the HAM-D and the Hamilton Anxiety Rating Scale (HAM-A). Using HAM-D criteria, women were significantly more likely to respond to sertraline than to imipramine (72.2% vs. 52.1%, P=.008), whilst men respond similarly to sertraline and to imipramine (56.5% vs. 59.3%, P>.05). Response analysis based on HAM-A shows similar results (women: 68.9% vs. 43.6%, P=.001; men: 56.5% vs. 51.9%, P>.05). Women taking sertraline show statistically significant higher reductions in HAM-D, HAM-A, and in CGI-S than women taking imipramine. The proportion of women who dropped out due to adverse events was much lower in sertraline than in imipramine (10.9% vs. 27.8%, P=.006), with no differences between treatments in men (8.3% vs. 11.5%, P>.05). It was concluded that sertraline is more effective and better tolerated than imipramine in the acute treatment of nonmelancholic depressive disorders in women, whereas men responded similarly to sertraline and to imipramine.

Therapeutic implications of sex differences in asthma and atopy

Clear sex differences exist in asthma and atopy with a preponderance of boys before puberty. There is a reversal of this sex ratio during puberty with girls having more asthma and atopy throughout the reproductive years. Elucidating the reasons for the switch in the sex ratio should provide fresh insights into asthma and atopy with a real prospect of novel therapies for these troublesome diseases. The challenge is to match the epidemiology and physiology with the accumulating scientific knowledge on gender differences in immune responses. Hormonal changes have been implicated in the reversal of the sex ratio. Testosterone is an immunosuppressant and is likely to be protective, while female sex steroids are proinflammatory and will increase the susceptibility to atopy. Modified so as to be non-virilising/feminising, sex steroids could therefore play a useful part in modulating the immunological and inflammatory processes that underlie asthma and other allergic disorders, complementing the currently used glucocorticoid derived steroids.

Estradiol in premenstrual asthma: a double-blind, randomized, placebo-controlled, crossover study

STUDY OBJECTIVES

To characterize asthma symptoms and pulmonary function throughout two menstrual cycles, with and without exogenous estradiol administration, in women with premenstrual asthma, and to determine the effect of estradiol administration on asthma symptoms, pulmonary function, quality of life, and biomarkers of airway inflammation.

DESIGN

Double-blind, randomized, placebo-controlled, crossover study.

SETTING

Respiratory clinic and clinical research center.

SUBJECTS

Twelve women with documented premenstrual asthma (> or = 20% premenstrual worsening of asthma symptoms and/or of peak expiratory flow [PEF] during a 1-month screening phase).

INTERVENTION

Each woman received either estradiol 2 mg or placebo orally between cycle days 23 and 28 (i.e., premenstrually, or before the onset of menses) in the first cycle and then crossed over to the other arm in the second cycle. Throughout both cycles, the women recorded daily morning and evening PEF readings and asthma symptoms.

MEASUREMENTS AND MAIN RESULTS

Spirometry testing and measurement of serum estradiol and biomarkers of airway inflammation were performed on days 8 (follicular phase), 22 (luteal phase), and 28 (premenstrually) of both the estradiol and placebo cycles. During the two premenstrual visits, the Asthma Quality of Life Questionnaire was administered. No notable differences were observed between the estradiol and placebo cycles in daily PEF recordings or composite asthma symptoms scores. The area under the curve (AUC) for the composite asthma symptoms versus time profile was numerically, but not statistically, lower (denoting less severe symptoms) during the estradiol cycle than during the placebo cycle. Likewise, no significant difference in AUC values for morning PEF or evening PEF was found between the estradiol cycle and the placebo cycle. Despite differences (p<0.05) in day-28 estradiol concentrations for estradiol and placebo cycles, no significant differences were found in forced expiratory volume in 1 second, serum endothelin-1, serum and urine eosinophil protein X, urine leukotriene E4, or quality-of-life scores.

CONCLUSION

Exogenously administered estradiol did not have a significant effect in women with premenstrual asthma whose asthma was classified predominantly as mild and under excellent control. As in the case of premenstrual syndrome, the placebo effect may be prominent in premenstrual asthma. Further trials, involving women with more severe asthma under poorer control, are warranted to discern underlying mechanisms for the worsening of asthma in relation to menstruation.

Depression and anxiety disorders

Depressive and anxiety disorders are common problems facing obstetrician-gynecologists. Although psychiatric disorders are equally common in men and women, women are at least twice as likely to present with depressive disorders and most anxiety disorders. The depressive disorders include major depression, dysthymia, seasonal affective disorder, and premenstrual dysphoric disorder. The anxiety disorders are panic disorder (with and without agoraphobia), generalized anxiety disorder, social phobia, obsessive compulsive disorder, and PTSD. One must diagnose and manage depressive and anxiety disorders during pregnancy, the purpureum, and while breastfeeding. General treatment principles include assessing suicide risk, psychotherapy, pharmacologic treatment, and an appropriate medical work-up for depressive and anxiety disorders. The SSRIs are the first-line treatment for most depressive and anxiety disorders because of data supporting their efficacy, the minimal need for dosage titration, the overall favorable side-effect profile, and the length of available clinical experience. Newer antidepressants, such as venlafaxine, bupropion, nefazodone, and mirtazapine, are options for patients unresponsive to, or intolerant of, the SSRIs. Treatment considerations include acute, maintenance, and continuation therapy, dosage regimens, adverse effects, and drug interactions. Specific guidelines are available for referring patients to a mental health specialist.

Peak expiratory flow rate and premenstrual symptoms in healthy nonasthmatic women

STUDY OBJECTIVES

To characterize intrasubject, intersubject, and diurnal variability in peak expiratory flow rates (PEFR) of healthy nonasthmatic women over at least one complete menstrual cycle; to determine whether a relationship exists between PEFR and premenstrual symptoms in these women; and to provide a forum to educate women pharmacy students by interactive study participation.

DESIGN

Longitudinal, investigator-blinded study.

SETTING

University of British Columbia and Children's and Women's Health Centre.

PATIENTS

Forty healthy nonasthmatic female pharmacy students were enrolled, and 31 (aged 22.1+/-1.5 yrs) completed the study.

INTERVENTION

Women were followed for at least one menstrual cycle during which they recorded premenstrual symptom questionnaire scores daily (15 mood and physical symptoms, graded 0-3 in severity). They also measured and recorded PEFR (3 consecutive attempts) every morning and every evening. A feedback survey was later administered by electronic mail.

MEASUREMENTS AND MAIN RESULTS

Thirty-one women, 28 of whom were of Asian descent, completed the study. Over half of them (58.1%) showed classic patterns of premenstrual symptoms, whereas PEFR fluctuated randomly over the course of the cycle. Average coefficients of variation (CVs) were 4.17+/-2.09% for morning PEFR, 3.97+/-2.25% for evening PEFR, and 3.72+/-2.55% for mean daily PEFR. Average absolute diurnal variation was 17.13+/-12.46 L/minute, and relative diurnal variation was 3.98+/-2.52%. Intersubject variability for morning, evening, and mean daily PEFRs yielded low CVs of 13.7%, 14.3%, and 13.9%, respectively Only 14 (11.3%) of 124 correlations between PEFR and premenstrual symptoms were significant (p<0.05). Most participants responded positively (mean score 3.87 on a 5-point scale) to the survey on the impact of this study.

CONCLUSION

Intrasubject and diurnal variability in PEFR are minimal in nonasthmatic women; similarly, intersubject variability is relatively low. The menstrual cycle appears to have little effect on PEFR in healthy nonasthmatic Asian women. Pharmacy students who take part in serial PEFR monitoring gain new appreciation for asthma and asthmatic patients.