Levels of serum steroid hormones in intrauterine contraceptive device users

Salivary Cortisol and Cortisone Can Circumvent Confounding Effects of Oral Contraceptives in the Short Synacthen Test

CONTEXT

Adrenal insufficiency (AI) is usually diagnosed by low plasma cortisol levels following a short Synacthen test (SST). Most plasma cortisol is bound to corticosteroid-binding globulin, which is increased by estrogen in combined estrogen-progestin oral contraceptives (COCs). Women with AI using COCs are therefore at risk of having an apparently normal plasma cortisol level during SST, which would not adequately reflect AI.

OBJECTIVE

This work aimed to test whether salivary cortisol or cortisone during SST is more robust against the COC effect and to calculate the lower reference limits (LRLs) for these to be used as tentative diagnostic cutoffs to exclude AI.

METHODS

Forty-one healthy women on COCs and 46 healthy women without exogenous estrogens underwent an SST with collection of plasma and salivary samples at 0, 30, and 60 minutes after Synacthen injection. The groups were compared using regression analysis with age as covariate and the LRLs were calculated parametrically.

RESULTS

SST-stimulated plasma cortisol levels were significantly higher in the COC group vs controls, while mean salivary cortisol and cortisone levels were slightly lower in the COC group. Importantly, COC use did not significantly alter LRLs for salivary cortisol or cortisone. The smallest LRL difference between groups was seen for salivary cortisone.

CONCLUSION

Salivary cortisol and especially salivary cortisone are considerably less affected by COC use than plasma cortisol during SST. Due to similar LRLs, a common cutoff for salivary cortisol and cortisone during SST can be used to exclude AI in premenopausal women irrespective of COC use.

Reproductive history and risk of depressive symptoms in postmenopausal women: A cross-sectional study in eastern China

BACKGROUND

Although there are potential mechanisms of female hormones in depression, conflicting results still exist in epidemiological studies. This study aimed to determine whether reproductive history, an important indicator of estrogen exposure across the lifetime, is associated with risk of depressive symptoms in postmenopausal women.

METHODS

We analyzed the baseline data from Zhejiang Ageing and Health Cohort Study including 5537 postmenopausal women. Depressive symptoms were assessed through the application of Patient Health Questionnaire-9 scale (PHQ-9). Logistic regression models, controlling for an extensive range of potential confounders, were generated to examine the association between reproductive history and risk of depressive symptoms in later life.

RESULTS

Longer reproductive period (Odds Ratio (OR) = 0.972, 95% Confidence Interval (CI) 0.955-0.989), regular menstrual cycle (OR = 0.723, 95% CI 0.525-0.995), later age at first gave birth (OR = 0.953, 95% CI 0.919-0.988) were significantly associated with a reduced risk of late-life depressive symptoms. Among women with regular menstrual cycle, longer cycle length increased the risk (OR = 1.050, 95% CI 1.016-1.085). Meanwhile, more full-term pregnancies and more incomplete pregnancies were related to higher prevalence of depressive symptoms. Women who underwent tubal sterilization as only type of contraceptive surgery were found less likely to suffer depressive symptoms in later life (OR = 0.433, 95% CI 0.348-0.538).

LIMITATIONS

Cross-sectional data could not make a causation conclusion.

CONCLUSIONS

Our results indicated that reproductive factors were significantly associated with risk of depressive symptoms in postmenopausal women. Further longitudinal studies are needed.

Copper-T intrauterine device and levonorgestrel intrauterine system: biological bases of their mechanism of action

All intrauterine devices (IUDs) that have been tested experimentally or clinically induce a local inflammatory reaction of the endometrium whose cellular and humoral components are expressed in the tissue and the fluid filling the uterine cavity. Depending on the reproductive strategy of the species considered and the anatomical features and physiologic mechanisms that characterize their reproductive system, the secondary consequences of this foreign body reaction can be very localized within the uterus, as in the rabbit, or widespread throughout the entire genital tract as in women or even systemic as in some farm animals. Levonorgestrel released from an IUD causes some systemic effects, but local effects such as glandular atrophy and stromal decidualization, in addition to the foreign body reaction, are dominant. Copper ions released from an IUD enhance the inflammatory response and reach concentrations in the luminal fluids of the genital tract that are toxic for spermatozoa. In the human, the entire genital tract appears affected due to luminal transmission of the noxa that accumulates in the uterine lumen. This affects the function and viability of gametes, decreasing the rate of fertilization and lowering the chances of survival of any embryo that may be formed, before it reaches the uterus. The bulk of the data indicate that if any embryos are formed in the chronic presence of an IUD, it happens at a much lower rate than in non-IUD users. The common belief that the usual mechanism of action of IUDs in women is destruction of embryos in the uterus is not supported by empirical evidence.

Mechanisms of action of intrauterine devices

The major effect of all intrauterine devices (IUD) is to induce a local inflammatory reaction in the endometrium whose cellular and humoral components are released into the uterine cavity. This inflammatory reaction has a variable effect on the reproductive strategy of the species studied. For example, this foreign body reaction can be localized within the uterus of rodents; and in farm animals it can have striking extrauterine effects. Thus, the action of IUDs in humans cannot be discerned from animals. In humans, copper ions released from Cu-IUDs enhance the inflammatory response and reach concentrations in the luminal fluids of the genital tract that are toxic for spermatozoa and embryos. In women using the IUD, the entire genital tract seems affected, at least in part, because of luminal transmission of the fluids that accumulates in the uterine lumen. This affects the function or viability of gametes, decreasing the rate of fertilization and lowering the chances of survival of any embryo that may be formed, even before it reaches the uterus. Studies on the recovery of eggs from women using IUDs and from women not using contraception show that embryos are formed in the tubes of IUD users at a much lower rate compared with nonusers. This is believed to be the major action of IUDs. Therefore, the common belief that the major mechanism of action of IUDs in women is through destruction of embryos in the uterus (i.e., abortion) is not supported by the available evidence. In Cu-IUD users, it is likely that few spermatozoa reach the distal segment of the fallopian tube, those that encounter an egg may be in poor condition. Thus, the few eggs that are fertilized have little chance for development and their possibility for survival in the altered tubal milieu become worse as they approach the uterine cavity.