Depressive mood symptoms associated with ovarian suppression

OBJECTIVE

To determine if sertraline is helpful in the management of depressive symptoms associated with ovarian suppression during GnRH agonist therapy as compared with a placebo-controlled group.

DESIGN

Double-blind placebo-controlled prospective study design.

SETTING

An obstetrics/gynecological office specializing in infertility in an academic environment.

PATIENT(S)

Premenstrual women with laparoscopically diagnosed endometriosis who required GnRH agonist therapy for treatment and did not have significant depressive or premenstrual mood symptoms at baseline.

INTERVENTION(S)

Participants were randomly assigned to either the sertraline treatment group or to the placebo group for the 3-month duration of the GnRH agonist therapy.

MAIN OUTCOME MEASURE(S)

The 21-item Hamilton Rating Scale for Depression (HRSD), which is an instrument designed to assess depressive symptomatology.

RESULT(S)

A Hotellings T(2) test for repeated measure analysis indicated a statistically significant (P<.05) between-group difference across time for the HRSD (T(2) = 13.3; F[3, 28] = 4.1; P=.02) with the sertraline treatment group manifesting significantly fewer depressive symptoms than the control group.

CONCLUSION(S)

The results indicate that sertraline is an effective option in the management of depressive mood symptoms associated with ovarian suppression during GnRH agonist therapy.

Depressive symptoms associated with gonadotropin-releasing hormone agonists

The gonadotropin-releasing hormone (GnRH) agonists are a relatively new class of drugs that are potentially effective in treating disorders that are aggravated either by estrogen or testosterone. GnRH agonists are effective in the treatment of endometriosis, as well as other disorders, such as advanced prostrate cancer, precocious puberty and uterine leiomyomata. While the GnRH agonists reduce the extent of the endometrial lesions and the occurrence of pelvic pain associated with endometriosis, these agents are associated with physical and psychiatric side effects. The adverse effects of these agents are consistent with the physiological effects of ovarian suppression, such as vasomotor instability, vaginal dryness, and headaches. Preliminary results of a prospective, double-blind placebo-controlled study and an open label trial indicates that depressive mood symptoms increase in women treated with GnRH agonist therapy for endometriosis. Additional evidence suggest that sertraline effectively manages depressive mood symptoms associated with GnRH agonist therapy. The reason for the decline in mood on GnRH agonists is postulated to be associated with the decline in estrogen levels. Effective treatment strategies for depressive mood symptoms in women on GnRH agonists therapy may offer insight into the mechanisms of action of estrogen on mood.

Female hypoactive sexual disorder: case studies of physiologic androgen replacement

Menopause, surgical or naturally occurring, with reduced or deficient ovarian functioning has a major impact on morbidity and mortality in mid- to late life. A growing body of literature notes the role of androgens in maintaining women's health and emotional well-being. The administration of physiologic levels of testosterone replacement therapy as an adjunct to estrogen replacement requires further investigation. The Sexual Energy Scale was used to measure the patient's subjective experience of vitality or sexual energy with androgen replacement therapy. Three cases of women who had undergone a total abdominal hysterectomy with bilateral oophorectomy with complaints consistent with female hypoactive sexual desire disorder and free testosterone levels of < 2.0 pg/ml are presented. Physiologic androgen replacement is helpful in increasing sexual desire for some women.

Sertraline in the treatment of depression associated with gonadotropin-releasing hormone agonist therapy

BACKGROUND

Endometriosis is thought to affect 5-10% of reproductive age women in the general population and is commonly treated with gonadotropin-releasing hormone (GnRH) agonists. Recent studies suggest depressive symptoms are associated with women treated with GnRH agonist for endometriosis.

METHODS

A retrospective pilot study of 42 female patients, 22 in the treatment group (sertraline) and 20 in the control group (no sertraline), was conducted. All subjects had laproscopically diagnosed endometriosis and were treated with 24 weeks of GnRH agonist therapy. Assessment instruments included the Hamilton Depression Rating Scale and the Menopausal Symptom Index.

RESULTS

The results indicate that patients receiving concomitant sertraline reported significantly less depressive symptoms, but did not differ significantly in physical symptoms than the group receiving a GnRH agonist alone.

CONCLUSIONS

Antidepressants, such as sertraline, appear to be significantly helpful in the treatment of mood symptoms during the course of GnRH agonist therapy.

Female hypoactive sexual desire disorder due to androgen deficiency: clinical and psychometric issues

Menopause, surgical or naturally occurring, with reduced or deficient ovarian functioning has a major impact on morbidity and mortality in mid to late life. In particular, a growing body of literature is focusing on the role of androgens in maintaining women's health and emotional well-being. Further study is needed in the administration of physiologic levels of testosterone replacement therapy as an adjustment to estrogen replacement. The Sexual Energy Scale was developed to provide an objective means of measuring the change in a patient's subjective experience of vitality/sexual energy with androgen replacement therapy. The scale also provides a clinical indication for androgen replacement dosage adjustment. Advantages in using low doses of methyltestosterone in women with hypoactive sexual desire disorder are discussed.

Anxiety and mood disorders associated with gonadotropin-releasing hormone agonist therapy

Gonadotropin-releasing hormone (GnRH) agonists are synthetic derivatives of the native decapeptide produced by the hypothalamus. These agents cause a reversible suppression of the synthesis and release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) by the anterior pituitary gland. With GnRH agonist therapy, there is a resulting loss of endogenous ovarian gonadotropin stimulation and a severe hypo-estrogen state consistent with castrate levels of estrogen. Recently, GnRH agonists such as leuprolide and goserelin have been noted to be effective in treating mild to severe endometriosis. Side effects of these agents are consistent with the physiological effects of ovarian suppression, such as vasomotor instability, vaginal dryness, and headaches. However, despite some reports of emotional lability as an adverse effect of GnRH agonists, it appears that the occasional, rather severe psychiatric consequences of these agents are underappreciated. In this article, we present the case reports of 4 women of reproductive age with no prior psychiatric history who were treated with a GnRH agonist for endometriosis. These women developed symptoms consistent with various psychiatric disorders, including panic disorder and major depression with and without psychotic features. Three of these patients were given sertraline while on GnRH agonist therapy, which improved their mood and anxiety symptoms. Women undergoing GnRH agonist therapy may provide a model with which to investigate mood disorders during the perimenopausal stage of life.

Levonorgestrel as a postcoital contraceptive

Time-release pellets of levonorgestrel (LNG), the progestogenic hormone contained in the contraceptive system Norplant, were implanted subdermally in mice, after the animals had mated and ovulated but before uterine implantation of embryos would have occurred, to examine whether the hormone could reduce the number of embryos that subsequently implanted and, if so, when it had to be administered in the postcoital period to achieve that effect. Hybrid female mice (C57BL x CBA) were paired with breeder males (CD-1) and LNG pellets were implanted on day 0, the day on which copulation plugs were found, or on day 2 or day 3 in the postcoital period. Mice in some groups were sacrificed on day 14 of the gestation period, and numbers of fetuses and/or resorption sites were counted, while mice in other groups were allowed to go to term. When LNG pellets were implanted subdermally on day 0 of the postcoital period, pellets designed to release 1.5 mg of hormone in 21 days failed to exhibit a contraceptive effect, but pellets designed to release 5 mg of hormone in 90 days were totally effective in preventing uterine implantation of embryos. Although the 5 mg pellets did not prevent embryos from implanting in all cases when administered on day 2, they prevented pregnancies from going to term by causing resorption of those embryos that did implant. When the pellets were implanted as late as day 3 in the postcoital period, uterine implantation of embryos occurred and fetuses were carried to term. Results of the study indicate that subdermal implants of LNG inserted postcoitally can prevent uterine implantation of embryos in mice, and thereby prevent pregnancy, despite fertilization of oocytes having occurred, if the hormone implants are inserted before day 3 of the postcoital period.

Effects of levonorgestrel on capacity of mouse oocytes for fertilization and development

This study utilized a mouse model to examine whether levonorgestrel implants, such as Norplant, may exert their contraceptive effects in part by adversely affecting oocyte quality. Time-release pellets and silastic capsules containing levonorgestrel were implanted subdermally in mice and left in situ for periods of two or three months. After that time, mice were given injections of gonadotropins to stimulate ovulation and oocytes were obtained from the oviducts of the animals, inseminated, and subsequently cultured for 96 hrs, some in medium supplemented with levonorgestrel. The numbers of oocytes that were fertilized and the numbers that developed at least to the morula stage were determined. Levonorgestrel was not found to have an adverse effect on either fertilization or preimplantation development but instead was found in some cases to increase the proportion of oocytes fertilized and the proportion of embryos that developed to morulae. Results indicate that the contraceptive effect of levonorgestrel implants should be attributed to effects other than diminished oocyte quality and they further substantiate the safety of levonorgestrel, suggesting that it will not adversely affect early embryonic development in the event that a pregnancy should be initiated during its use.

Evaluation of human fetal cord sera, Ham's F-10 medium, and in vitro culture materials with a mouse in vivo fertilization system

A total of 54 human fetal cord sera, 42 lots of Ham's F-10 medium, and 36 lots of plastics were tested during a 10-month period with a mouse in vivo fertilization system. Two-cell embryos were collected from the oviducts of superovulated and mated (C57BL/6 X CBA)F1 mice. After collection, 2-cell embryos were distributed among test media and a modified Krebs-Ringer control medium. The test material passed quality control standards if a minimum of 80% of the original 2-cell embryos reached the blastocyst stage. Of the 54 cord sera examined, 8 (15%) were below our standards; 6 (14%) of the Ham's F-10 media and 4 (11%) of the plastics failed to pass minimum requirements. In all cases, the failed materials promoted slower-growing mouse embryos and increased the number of degenerates. It is our opinion that the mouse in vivo fertilization system has a valuable place in any in vitro fertilization program.

Immunotherapy with neuraminidase-treated cells and bacillus Calmette-Guerin

Experiments were designed to determine the effectiveness of active immunotherapy, both specific (neuraminidase-treated cells) and nonspecific [bacillus Calmette-Guerin (BCG) organisms] in the L1210-BDF1 tumor-host system. Tumor burden was minimized with chemotherapy (1,3-bis-(20chloroethyl)-1-nitrosourea) prior to immunotherapy. The effectiveness of immunotherapy was dependent on the amount of drug used to minimize tumor burden. An interval 36 hours between chemotherapy and immunotherapy produced the maximum number of survivors. A single immunization with 10(4) neuraminidase-treated cells was superior to other single or multiple immunizations. BCG was most effective when mice were given 393 X 10(5) organisms. Beneficial effects of immunotherapy were observed only when immunizations were given by an intraperitoneal route. All mice cured of tumor developed tumor-specific immunity. The highest levels of immunity were observed in mice given both neuraminidase-treated cells and BCG organisms after chemotherapy.