Symptomatology across the menstrual cycle in smoking and nonsmoking women

The importance of translationally evaluating steroid hormone contributions to substance use

Clinically, women appear to be more susceptible to certain aspects of substance use disorders (SUDs). The steroid hormones 17β-estradiol (E2) and progesterone (Pg) have been linked to women-specific drug behaviors. Here, we review clinical and preclinical studies investigating how cycling ovarian hormones affect nicotine-, cocaine-, and opioid-related behaviors. We also highlight gaps in the literature regarding how synthetic steroid hormone use may influence drug-related behaviors. In addition, we explore how E2 and Pg are known to interact in brain reward pathways and provide evidence of how these interactions may influence drug-related behaviors. The synthesis of this review demonstrates the critical need to study women-specific factors that may influence aspects of SUDs, which may play important roles in addiction processes in a sex-specific fashion. It is important to understand factors that impact women's health and may be key to moving the field forward toward more efficacious and individualized treatment strategies.

How Lifestyle Changes during the COVID-19 Global Pandemic Affected the Pattern and Symptoms of the Menstrual Cycle

This research investigated the implications that the COVID-19 pandemic had on the menstrual cycle and any contributing factors to these changes. A questionnaire was completed by 559 eumenorrheic participants, capturing detail on menstrual cycle symptoms and characteristics prior to and during the COVID-19 pandemic lockdown period. Over half of all participants reported to have experienced lack of motivation (61.5%), focus (54.7%) and concentration (57.8%). 52.8% of participants reported an increase in cycle length. Specifically, there was an increase in the median cycle length reported of 5 days (minimum 2 days, maximum 32 days), with a median decrease of 3 days (minimum 2 days and maximum 17 days). A lack of focus was significantly associated with a change in menstrual cycle length (p = 0.038) reported to have increased by 61% of participants. Changes to eating patterns of white meat (increase p = 0.035, decrease p = 0.003) and processed meat (increase p = 0.002 and decrease p = 0.001) were significantly associated with a change in menstrual cycle length. It is important that females and practitioners become aware of implications of environmental stressors and the possible long-term effects on fertility. Future research should continue to investigate any long-lasting changes in symptoms, as well as providing education and support for females undergoing any life stressors that may implicate their menstrual cycle and/or symptoms.

Sex Differences in Psychostimulant Abuse: Implications for Estrogen Receptors and Histone Deacetylases

Substance abuse is a chronic pathological disorder that negatively affects many health and neurological processes. A growing body of literature has revealed gender differences in substance use. Compared to men, women display distinct drug-use phenotypes accompanied by recovery and rehabilitation disparities. These observations have led to the notion that sex-dependent susceptibilities exist along the progression to addiction. Within this scope, neuroadaptations following psychostimulant exposure are thought to be distinct for each sex. This review summarizes clinical findings and animal research reporting sex differences in the subjective and behavioral responses to cocaine, methamphetamine, and nicotine. This discussion is followed by an examination of epigenetic and molecular alterations implicated in the addiction process. Special consideration is given to histone deacetylases and estrogen receptor-mediated gene expression.

Psychiatric Symptoms Across the Menstrual Cycle in Adult Women: A Comprehensive Review

LEARNING OBJECTIVE

After participating in this activity, learners should be better able to:• Discuss and outline the general and overlapping effects of the menstrual cycle on women's mental health.

ABSTRACT

A growing body of research demonstrates menstrual cycle-dependent fluctuations in psychiatric symptoms; these fluctuations can therefore be considered as prevalent phenomena. Possible mechanisms underlying these fluctuations posit behavioral, psychological, and neuroendocrine influences. Recent reviews document cyclic exacerbation of symptoms and explore these mechanisms in the context of specific and often single disorders. The question remains, however, as to whether there are general and overlapping effects of the menstrual cycle on women's mental health. To address this gap, we synthesized the literature examining the exacerbation of a variety of psychiatric symptoms across the menstrual cycle in adult women. Results show that the premenstrual and menstrual phases are most consistently implicated in transdiagnostic symptom exacerbation. Specifically, strong evidence indicates increases in psychosis, mania, depression, suicide/suicide attempts, and alcohol use during these phases. Anxiety, stress, and binge eating appear to be elevated more generally throughout the luteal phase. The subjective effects of smoking and cocaine use are reduced during the luteal phase, but fewer data are available for other substances. Less consistent patterns are demonstrated for panic disorder, symptoms of posttraumatic stress disorder, and borderline personality disorder, and it is difficult to draw conclusions for symptoms of generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, and trichotillomania because of the limited data. Future research should focus on developing standardized approaches to identifying menstrual cycle phases and adapting pharmacological and behavioral interventions for managing fluctuations in psychiatric symptoms across the menstrual cycle.

Addictive behaviors across the menstrual cycle: a systematic review

Research examining relations between menstrual cycle phase and female addictive behaviors is accumulating. Theories suggest addictive behaviors may increase during specific phases of the menstrual cycle resulting from cyclical fluctuations in hormones and affect. In line with self-medication theory, we predicted that addictive behaviors would increase premenstrually and menstrually, phases marked by elevations in negative affect, relative to the follicular and luteal phases. We also hypothesized, coinciding with reward-sensitivity theory, that addictive behaviors may increase during ovulation, a phase characterized by increased positive affect, compared to the same phases. This systematic review summarizes extant literature examining the menstrual cycle phase-addictive behavior relationship and underlying motivations. Articles pertaining to menstrual cycle phase and addictive behaviors within the PsycINFO, CINAL, and PubMED databases were screened to determine eligibility following PRISMA guidelines (n = 1568). Thirty-four articles examining alcohol use, cannabis use, nicotine use, caffeine use, and gambling behavior across menstrual cycle phase met inclusion criteria. Consistent with self-medication theory, strong evidence indicated that nicotine use increased premenstrually and menstrually. Other factors increasing both nicotine and alcohol use premenstrually and menstrually include having a premenstrual dysphoric disorder diagnosis or having premenstrual syndrome. Motivations for using alcohol and nicotine may too vary by menstrual cycle phase. Results were less consistent or understudied for other addictive behaviors and thus conclusions cannot be drawn. Menstrual cycle phase appears to be a female-specific factor affecting some addictive behaviors, particularly nicotine use, and should be considered when conducting addictive behavior research or clinical interventions for reproductive-aged females with addictive disorders.

Association Between Smoking and Premenstrual Syndrome: A Meta-Analysis

Results of basic science studies demonstrate shared actions of endogenous neuroactive steroid hormones and drugs of abuse on neurotransmission. As such, premenstrual syndrome (PMS) may be associated with smoking, however, results from studies examining this relationship have been mixed. Following PRISMA guidelines, we extracted unique studies examining the relationship between smoking and PMS. We used the escalc () function in R to compute the log odds ratios and corresponding sampling variance for each study. We based quality assessment on the nature of PMS diagnosis and smoking estimation, confounding adjustment, participation rate, and a priori specification of target population. Our final sample included 13 studies, involving 25,828 study participants. Smoking was associated with an increased risk for PMS [OR = 1.56 (95% CI: 1.25-1.93), p < 0.0001]. Stratified by diagnosis, the effect size estimate was higher for Premenstrual Dysphoric Disorder (PMDD) [OR = 3.15 (95% CI: 2.20-4.52), p < 0.0001] than for PMS [OR = 1.27 (95% CI: 1.16-1.39), p < 0.0001]. We review some of the basic mechanisms for the observed association between smoking and PMS. Given nicotine's rewarding effects, increased smoking behavior may be a mechanism to alleviate affective symptoms of PMS. However, smoking may lead to worsening of PMS symptoms because nicotine has effects on neurocircuitry that increases susceptibility to environmental stressors. Indeed, prior evidence shows that the hypothalamic-pituitary-adrenal (HPA) axis is already sub-optimal in PMS, hence, smoking likely further deteriorates it. Combined, this complicates the clinical course for the treatment of both PMS and Tobacco Use Disorder in this population.

Do women expose themselves to more health-related risks in certain phases of the menstrual cycle? A meta-analytic review

Researchers have increasingly examined the menstrual cycle as a potential source of day-to-day variation in women's cognitions, motivations, and behavior. Within this literature, several lines of research have examined the impact of the menstrual cycle on women's engagement in activities that could negatively affect their health (alcohol and tobacco consumption, sexual behavior, risk recognition). However, findings have been mixed, leaving it unclear whether women may expose themselves to more health-related risks during certain phases of the cycle. We conducted a meta-analysis of 22 published and four unpublished studies (N = 7529, https://osf.io/xr37j/). The meta-analysis revealed shifts across the menstrual cycle in women's sexual behavior with others and risk recognition (higher in ovulatory phase), whereas there was no consistent pattern of difference for alcohol and cigarette consumption. These findings help to clarify the proximate physiological and evolutionary mechanisms underlying women's health-related risk-taking and may inform new interventions.

Smoking-related symptomatology in pregnant smokers during ad libitum smoking and following overnight smoking abstinence

Objective

Current literature suggests there may be a relationship between sex hormones, which dramatically increase during pregnancy, and nicotine use behaviors. We hypothesized that higher progesterone and progesterone:estradiol ratio (P/E₂) would be associated with less smoking-related symptomatology (SRS), better mood and fewer cigarettes smoked per day (CPD) during ad libitum smoking and following overnight abstinence in pregnant women. Associations between SRS, mood, smoking behavior and sex hormones were estimated using multiple linear regression with adjustment for CPD and pregnancy trimester.

Results

There were 35 second trimester and 42 third trimester participants. Participants mean age was 26.2 (SD: 4.1), they smoked 11.3 CPD (SD: 4.4) and the mean nicotine dependence score was 4.94 (SD: 1.98). There were no statistically significant associations between progesterone levels, estradiol levels, or the P/E₂ ratio and SRS or mood measures during ad libitum smoking or following overnight abstinence in this sample of pregnant women. Similarly, there were no associations between sex hormone levels and number of CPD smoked during the ad libitum period. Contrary to our hypothesis, we found no significant associations between sex hormones and SRS, mood or smoking behavior in this sample of pregnant women.

Trial registration ClinicalTrials.gov (NCT01811225), December 6, 2012

Sex and gender differences in substance use disorders

The gender gap in substance use disorders (SUDs), characterized by greater prevalence in men, is narrowing, highlighting the importance of understanding sex and gender differences in SUD etiology and maintenance. In this critical review, we provide an overview of sex/gender differences in the biology, epidemiology and treatment of SUDs. Biological sex differences are evident across an array of systems, including brain structure and function, endocrine function, and metabolic function. Gender (i.e., environmentally and socioculturally defined roles for men and women) also contributes to the initiation and course of substance use and SUDs. Adverse medical, psychiatric, and functional consequences associated with SUDs are often more severe in women. However, men and women do not substantively differ with respect to SUD treatment outcomes. Although several trends are beginning to emerge in the literature, findings on sex and gender differences in SUDs are complicated by the interacting contributions of biological and environmental factors. Future research is needed to further elucidate sex and gender differences, especially focusing on hormonal factors in SUD course and treatment outcomes; research translating findings between animal and human models; and gender differences in understudied populations, such as those with co-occurring psychiatric disorders and gender-specific populations, such as pregnant women.

Systematic and meta-analytic review of research examining the impact of menstrual cycle phase and ovarian hormones on smoking and cessation

INTRODUCTION

To determine the effect of ovarian hormones on smoking, we conducted a systematic review of menstrual cycle effects on smoking (i.e., ad lib smoking, smoking topography, and subjective effects) and cessation-related behaviors (i.e., cessation, withdrawal, tonic craving, and cue-induced craving).

METHODS

Thirty-six papers were identified on MEDLINE that included a menstrual-related search term (e.g., menstrual cycle, ovarian hormones), a smoking-related search term (e.g., smoking, nicotine), and met all inclusion criteria. Thirty-two studies examined menstrual phase, 1 study measured hormone levels, and 3 studies administered progesterone.

RESULTS

Sufficient data were available to conduct meta-analyses for only 2 of the 7 variables: withdrawal and tonic craving. Women reported greater withdrawal during the luteal phase than during the follicular phase, and there was a nonsignificant trend for greater tonic craving in the luteal phase. Progesterone administration was associated with decreased positive and increased negative subjective effects of nicotine. Studies of menstrual phase effects on the other outcome variables were either small in number or yielded mixed outcomes.

CONCLUSIONS

The impact of menstrual cycle phase on smoking behavior and cessation is complicated, and insufficient research is available upon which to conduct meta-analyses on most smoking outcomes. Future progress will require collecting ovarian hormone levels to more precisely quantify the impact of dynamic changes in hormone levels through the cycle on smoking behavior. Clarifying the relationship between hormones and smoking-particularly related to quitting, relapse, and medication response-could determine the best type and timing of interventions to improve quit rates for women.

Sex differences and menstrual cycle phase-dependent modulation of craving for cigarette: an FMRI pilot study

While overall more men than women smoke cigarettes, women and girls take less time to become dependent after initial use and have more difficulties quitting the habit. One of the factors contributing to these differences may be that women crave cigarettes more than men and that their desire to smoke is influenced by hormonal fluctuations across the menstrual cycle. Therefore, the purpose of the present study was twofold: (a) to examine potential sex/gender differences in functional neuroanatomy of craving and to (b) delineate neural correlates of cigarette cravings in women across their menstrual cycle. Fifteen tobacco-smoking men and 19 women underwent a functional MRI during presentation of neutral and smoking-related images, known to elicit craving. Women were tested twice: once during early follicular phase and once during midluteal phase of their menstrual cycle. The analysis did not reveal any significant sex differences in the cerebral activations associated with craving. Nevertheless, the pattern of activations in women varied across their menstrual cycle with significant activations in parts of the frontal, temporal, and parietal lobe, during follicular phase, and only limited activations in the right hippocampus during the luteal phase.

Subjective, physiological, and cognitive responses to intravenous nicotine: effects of sex and menstrual cycle phase

Nicotine dependence is a serious public health concern. Optimal treatment of nicotine dependence will require greater understanding of the mechanisms that contribute to the maintenance of smoking behaviors. A growing literature indicates sex and menstrual phase differences in responses to nicotine. The aim of this study was to assess sex and menstrual phase influences on a broad range of measures of nicotine response including subjective drug effects, cognition, physiological responses, and symptoms of withdrawal, craving, and affect. Using a well-established intravenous nicotine paradigm and biochemical confirmation of overnight abstinence and menstrual cycle phase, analyses were performed to compare sex (age 18-50 years; 115 male and 45 female) and menstrual cycle phase (29 follicular and 16 luteal) effects. Females had diminished subjective drug effects of, but greater physiological responses to, nicotine administration. Luteal-phase females showed diminished subjective drug effects and better cognition relative to follicular-phase women. These findings offer candidate mechanisms through which the luteal phase, wherein progesterone is dominant relative to estradiol, may be protective against vulnerability to smoking.

The many faces of tobacco use among women

Smoking is still considered to be mainly a male problem. However, it is estimated that there are approximately 250 million women worldwide who smoke cigarettes and millions more women who use smokeless tobacco products. This article addresses the many facets of tobacco use among women. The aim of the paper is to increase recognition among clinicians and researchers of the specific characteristics of female tobacco use. Together with providing epidemiological data on the distribution of tobacco use among women and data from population-based analyses on sociocultural factors that influence it, the article presents tobacco use during pregnancy as a particularly important public health problem. Further, the article points out sex-related differences (ie, physiological, psychological, or behavioral) between male and female tobacco use. A special focus is on the important role of ovarian hormones. Adverse effects of tobacco use to women and their children as well as tobacco-related morbidities and comorbidities are presented, and women's greater susceptibility to tobacco constituents as compared to men is stressed. Awareness of these differences can contribute to improvement of the effectiveness of smoking cessation programs addressed both to the specific female population and to an individual smoking woman.

Association of menstrual phase with smoking behavior, mood and menstrual phase-associated symptoms among young Japanese women smokers

BACKGROUND

Previous studies of the relationship between the menstrual phases and smoking behavior have been problematic, so the association of menstrual phases with smoking behavior and correlations among smoking, psychological and physical conditions in each phase of the menstrual cycle are unclear.

METHODS

To accurately examine the association between menstrual phases and the amount of smoking (number of cigarettes smoked and breath CO concentration), craving of smoking on visual analogue scale (VAS), depression in the Center for Epidemiologic Studies Depression (CES-D) Scale, and menstrual phase-associated symptoms in the Menstrual Distress Questionnaire (MDQ), we improved various methodological issues, specifically, 1) Ovulation was confirmed by measuring the basal body temperature and identifying a urinary luteinizing hormone (LH) surge in two cycles; 2) The menstrual, follicular, and luteal phases were clearly defined for subjects with different menstrual cycles; 3) The breath CO concentration was measured every day. A notice was posted on public bulletin boards to recruit research subjects and twenty-nine young Japanese women smokers aged 19 to 25 years old were analyzed.

RESULTS

The number of cigarettes smoked was greater and the CO concentration was higher in the luteal phase than in the follicular phase. The levels of craving for smoking (VAS), depressiveness (CES-D), and menstrual phase-associated symptoms (MDQ) in the menstrual and luteal phases were higher than those in the follicular phase. The mean score for CES-D was 16 points (the cut-off value in screening for depression) or higher in the menstrual (16.9 ± 8.2) and luteal phases (17.2 ± 8.4).The number of cigarettes smoked and CO concentration were significantly correlated with the levels of craving for smoking, depressiveness, and menstrual phase-associated symptoms in all phases except for MDQ scores in follicular phase. The amount of smoking in the luteal phase was most strongly correlated with these symptoms.

CONCLUSIONS

In the menstrual and luteal phases, young Japanese women smokers increased their amount of smoking and suffered from greater craving for smoking, depressiveness and menstrual phase-associated symptoms. The amount of smoking was correlated with these symptoms, but their cause-effect relationship has not been determined yet.

Association between ovarian hormones and smoking behavior in women

Studies examining the association between menstrual cycle phases and smoking behavior in women have yielded mixed results. The purpose of this study was to elucidate the associations between ovarian hormones and smoking by directly measuring ovarian hormone levels and obtaining a laboratory assessment of smoking behaviors. Four hypotheses were tested: Increased smoking will be associated with (1) low absolute levels of estradiol and progesterone; (2) decreasing (i.e., dynamic changes in) estradiol and progesterone; (3) lower ratios of progesterone to estradiol; and (4) higher ratios of estradiol to progesterone. Female smokers (≥10 cigarettes/day) with regular menstrual cycles were recruited as part of a larger, ongoing study examining the influence of ovarian hormones on smoking cessation treatment. Participants completed 2 study visits, including a 1-hr ad lib smoking topography session, which provided a detailed assessment of smoking behavior. Both the change in hormone levels over time and the relative ratios of ovarian hormones were associated with smoking behavior, but each to a limited extent. Decreases in estradiol (r = -.21, p = .048) and decreases in progesterone (r = -.23, p = .03) were associated with increased puff intensity. Lower ratios of progesterone to estradiol were associated with a greater number of puffs (r = -.26, p = .01) and weight of cigarettes smoked (r = -.29, p = .005). The best predictors of smoking behavior were the ratio of progesterone to estradiol (z = -2.7, p = .004) and the change in estradiol and progesterone over time (z = -2.1, p = .02). This pattern of results may help to explain inconsistent findings in previous studies and suggest potential mechanisms by which hormones influence nicotine addiction.

Novel actions of progesterone: what we know today and what will be the scenario in the future?

Objectives

This article is aimed to review the novel actions of progesterone, which otherwise is considered as a female reproductive hormone. The article focuses on its important physiological actions in males too and gives an overview of its novel perspectives in disorders of central and peripheral nervous system.

Key findings

Progesterone may have a potential benefit in treatment of traumatic brain injury, various neurological disorders and male related diseases like benign prostatic hypertrophy (BPH), prostate cancer and osteoporosis. Norethisterone (NETA), a progesterone derivative, decreases bone mineral loss in male castrated mice suggesting its role in osteoporosis. In the future, progesterone may find use as a male contraceptive too, but still needs confirmatory trials for safety, tolerability and acceptability. Megestrol acetate, a progesterone derivative is preferred in prostatic cancer. Further, it may find utility in nicotine addiction, traumatic brain injury (recently entered Phase III trial) and Alzheimer's disease, diabetic neuropathy and crush injuries. Studies also suggest role of progesterone in stroke, for which further clinical trials are needed. The non genomic actions of progesterone may be in part responsible for these novel actions.

Summary

Although progesterone has shown promising role in various non-hormonal benefits, further clinical studies are needed to prove its usefulness in conditions like stroke, traumatic brain injury, neuropathy and crush injury. In male related illnesses like BPH and prostatic Ca, it may prove a boon in near future. New era of hormonal male contraception may be initiated by use of progesterone along with testosterone.

Sex, ADHD symptoms, and smoking outcomes: an integrative model

Both females and individuals with Attention-Deficit/Hyperactivity Disorder (ADHD) have been found to be at increased risk for a range of smoking outcomes, and recent empirical findings have suggested that women with ADHD may be particularly vulnerable to nicotine dependence. On a neurobiological level, the dopamine reward processing system may be implicated in the potentially unique interaction of nicotine with sex and with ADHD status. Specifically, nicotine appears to mitigate core ADHD symptoms through interaction with the dopamine reward processing system, and ovarian hormones have been found to interact with nicotine within the dopamine reward processing system to affect neurotransmitter release and functioning. This article synthesizes data from research examining smoking in women and in individuals with ADHD to build an integrative model through which unique risk for cigarette smoking in women with ADHD can be systematically explored. Based upon this model, the following hypotheses are proposed at the intersection of each of the three variables of sex, ADHD, and smoking: (1) individuals with ADHD have altered functioning of the dopamine reward system, which diminishes their ability to efficiently form conditioned associations based on environmental contingencies; these deficits are partially ameliorated by nicotine; (2) nicotine interacts with estrogen and the dopamine reward system to increase the positive and negative reinforcement value of smoking in female smokers; (3) in adult females with ADHD, ovarian hormones interact with the dopamine reward system to exacerbate ADHD-related deficits in the capacity to form conditioned associations; and (4) during different phases of the menstrual cycle, nicotine and ovarian hormones may interact differentially with the dopamine reward processing system to affect the type and value of reinforcement smoking provides for women with ADHD. Understanding the bio-behavioral mechanisms underlying cigarette addiction in specific populations will be critical to developing effectively tailored smoking prevention and cessation programs for these groups. Overall, the goal of this paper is to examine the interaction of sex, smoking, and ADHD status within the context of the dopamine reward processing system not only to elucidate potential mechanisms specific to female smokers with ADHD, but also to stimulate consideration of how the examination of such individual differences can inform our understanding of smoking more broadly.

Menstrual cycle phase at quit date and smoking abstinence at 6 weeks in an open label trial of bupropion

BACKGROUND

Quit attempts may have different outcomes based on menstrual cycle phase on quit day. This is the first preliminary study examining whether smoking cessation outcomes vary by menstrual cycle phase of quit date in women receiving a 6-week open trial of sustained release (SR) bupropion.

METHODS

Thirty-three treatment-seeking premenopausal women were studied. Abstinence outcomes were compared for women quitting during the luteal versus follicular phase.

RESULTS

Women receiving bupropion SR whose self-selected quit date occurred in the luteal phase had significantly higher rates of point prevalence abstinence during the final week of a 6-week post-quit treatment period than women quitting in the follicular phase (62.5% versus 29.4%; p<0.05). A similar, but non-significant, pattern of findings was demonstrated for continuous abstinence during the treatment phase and for point prevalence abstinence at 3-month follow-up.

CONCLUSIONS

Women receiving bupropion SR were significantly more likely to be abstinent at treatment completion if quitting occurred during the luteal phase. This is consistent with recent findings of outcome related to cycle phase at quit date in the absence of pharmacotherapy, and differs from findings utilizing nicotine replacement. Results add to emerging data suggesting that smoking cessation interventions with varying mechanisms of action may result in different outcomes for premenopausal women based on gonadal hormones at quit date.

Role of progesterone in nicotine addiction: evidence from initiation to relapse

Nicotine addiction continues to be the main cause of preventable death in developed countries. Women and teen girls appear to be more vulnerable on certain aspects of nicotine addiction compared with men and boys. While the mechanism of gender differences in nicotine addiction is not yet clear, evidence suggests that while estrogen may underlie enhanced vulnerability in females, progesterone may protect females. Thus, progesterone may have therapeutic use for tobacco addiction, especially in female smokers. A greater understanding of the role of progesterone in nicotine addiction is important not only from a treatment standpoint, but also from a prevention standpoint: hormone transition phases, such as those that occur at adolescence, and during pregnancy and following birth, as well as following hormonal manipulation (e.g., using methods of hormonal birth control), may all contribute to changes in vulnerability to nicotine addiction. In this review, we summarize recent evidence from clinical and preclinical studies examining the role of progesterone in nicotine addiction focusing on its role during initiation of use and during later phases of the addiction process as a potential relapse prevention treatment. We conclude with future directions including further examination of progesterone as a potential intervention and treatment of nicotine addiction.

Premenstrual and menstrual symptomatology in young adult Japanese females who smoke tobacco

AIM

The present study examines the correlation between premenstrual and menstrual symptomatology and smoking status in young adult Japanese females.

MATERIAL AND METHODS

A cross-sectional study was conducted to assess premenstrual and menstrual symptomatology using the Moos Menstrual Distress Questionnaire (MDQ). Findings were compared between smokers and nonsmokers. The correlation between symptomatology and smoking status assessed by the Fagerström Test for Nicotine Dependency (FTND) and the Reasons for Smoking Scale (RSS), which identifies smoker's motives, was determined.

RESULTS

Data were obtained from 785 participants, including 71 smokers, 29 quitters and 685 nonsmokers. All smokers consumed 20 or fewer cigarettes per day with the exception of one heavy smoker. Smoking status affected the cycle of menstruation, but did not affect the duration. Smokers demonstrated more severe symptomatology than nonsmokers during the menstrual and premenstrual phases. Among smokers, premenstrual symptomatology was significantly more severe than menstrual symptomatology. Five premenstrual symptom groups (pain, concentration, water retention, behavior change and negative affect) were significantly higher in smokers than in nonsmokers. Overall MDQ scores and those of three subcategories (concentration, behavior change, and negative affect) during the premenstrual phase were significantly correlated with nicotine dependency and smoking motives. Smoking motives were also correlated with the severity of autonomic reaction.

CONCLUSION

Our findings suggest that young adult Japanese females with a light smoking habit have severe premenstrual symptomatology, which was correlated with nicotine dependency and smoking motives.

Severity of withdrawal symptomatology in follicular versus luteal quitters: The combined effects of menstrual phase and withdrawal on smoking cessation outcome

Women are at an increased risk of relapse after a smoking cessation attempt. While the reasons for this phenomenon are not fully understood, recent research indicates that both the menstrual cycle and negative symptomatology may play a role. The goal of this study was to describe the association between withdrawal symptoms during attempted smoking cessation, and to investigate the impact of these symptoms on smoking cessation outcomes as defined by 7-day point prevalence at 14 and 30 days. Negative symptoms associated with the premenstrual period were also assessed. Participants (n = 202) were 29.8 (SD +/- 6.6) years old and smoked 16.6 (SD +/- 5.6) cigarettes per day. They were randomly assigned to quit smoking in the follicular (n = 106) or luteal (n = 96) menstrual phase. We observed several significantly more severe premenstrual and withdrawal symptoms in the luteal phase. Regardless of quit phase, most withdrawal symptoms were associated with an increased risk of relapse at 14 and 30 days post quit date. Participants attempting to quit smoking in the follicular phase who had higher levels of Anger and Craving were more likely to relapse to smoking at 14-days (OR = 2.00, p-value = 0.026; OR = 2.63, p-value = 0.006; respectively). These data suggest that the menstrual cycle may play a role in smoking cessation outcome, as well as in the symptomatology experienced during a cessation attempt.

The role of progestins in the behavioral effects of cocaine and other drugs of abuse: human and animal research

This review summarizes findings from human and animal research investigating the influence of progesterone and its metabolites allopreganolone and pregnanolone (progestins) on the effects of cocaine and other drugs of abuse. Since a majority of these studies have used cocaine, this will be the primary focus; however, the influence of progestins on other drugs of abuse will also be discussed. Collectively, findings from these studies support a role for progestins in (1) attenuating the subjective and physiological effects of cocaine in humans, (2) blocking the reinforcing and other behavioral effects of cocaine in animal models of drug abuse, and (3) influencing behavioral responses to other drugs of abuse such as alcohol and nicotine in animals. Administration of several drugs of abuse in both human and nonhuman animals significantly increased progestin levels, and this is explained in terms of progestins acting as homeostatic regulators that decrease and normalize heightened stress and reward responses which lead to increased drug craving and relapse. The findings discussed here highlight the complexity of progestin-drug interactions, and they suggest a possible use for these agents in understanding the etiology of and developing treatments for drug abuse.

Circadian patterns of ad libitum smoking by menstrual phase

OBJECTIVE

Recent research suggests nicotine metabolism may be influenced by sex hormones. Thus, we hypothesized that circadian smoking patterns would vary by menstrual phase.

METHODS

Healthy female smokers (n = 31) between the ages of 18 and 40 with regular menstrual cycles, and not using hormones or psychotropic medications, were recruited for a randomized clinical study. Subjects recorded the time of each cigarette smoked and their menstrual phase with daily diaries prospectively for one complete menstrual cycle of ad libitum smoking. Analyses included Poisson regression to assess variations in the rate of smoking during waking hours (i.e., 6:00 a.m. and 12:00 midnight) and circadian smoking patterns by menstrual phase.

RESULTS

Participants were 29.61 +/- 5.44 years of age and smoked 16.93 +/- 5.37 cigarettes per day. Participants had a lower rate of smoking during waking hours in the follicular phase as compared to the menses phase. There were no significant menstrual phase differences in the circadian smoking patterns.

CONCLUSIONS

These results offer further support for the influence of sex hormones on smoking behavior, but not on circadian patterns of smoking. Additional research is needed to study the direct relationship between nicotine metabolism, sex hormones, menstrual phase, and smoking behavior.

Sex and ovarian hormones influence vulnerability and motivation for nicotine during adolescence in rats

The purpose of this study was to examine sex differences in sensitivity to nicotine's reinforcing effects during adolescence, a hormone transition phase characterized by rapid and marked changes in levels of gonadal hormones. Male and female rats were trained to self-administer nicotine (5 or 10 microg/kg/infusion) under a fixed-ratio 1 schedule beginning on postnatal day 30. Following acquisition, responding was assessed under a progressive-ratio schedule until postnatal day 45 with blood sampling occurring prior to the first 5 sessions in order to determine the relationship between gonadal hormones (i.e., estradiol and progesterone in females and testosterone in males) and responding for nicotine. Under low dose conditions, a greater percentage of females than males acquired nicotine self-administration. Under progressive-ratio testing conditions, although adolescent females and males initially responded at similar levels, by the end of the adolescent testing period, females responded at higher levels than males to obtain nicotine infusions. Levels of responding under the progressive-ratio schedule were negatively associated with progesterone and positively associated with the ratio of estradiol to progesterone. These findings demonstrate an enhanced sensitivity in adolescent females as compared to adolescent males to nicotine's reinforcing effects with evidence implicating circulating hormone levels as modulating this sensitivity.

Altered pattern of sympathetic activity with the ovarian cycle in female smokers

Smoking increases cardiovascular risk in young women and eliminates the protective effect of the premenopausal state. Increased sympathetic nervous system (SNS) activity is associated with increased cardiovascular risk. One potential mechanism by which smoking increases risk is through chronic SNS activation. It has been reported that premenopausal women have high SNS activity during the midluteal (ML) phase, which falls to low levels during the early follicular (EF) phase. We tested the hypothesis that smoking disrupts this fall in SNS activity during the EF phase. We measured blood pressure and muscle sympathetic nerve activity (MSNA) using microneurography in 11 premenopausal female smokers and 11 age-matched nonsmoking controls at two separate times during the ovarian cycle: ML phase (8-10 days after the luteinizing hormone surge) and EF phase (days 1-4 of the menstrual cycle). The change in MSNA from the EF phase to the ML phase was significantly different between the smoking and nonsmoking groups (P = 0.036). Whereas there was a significant decrease in MSNA from the ML phase to the EF phase among nonsmoking controls (22.7 +/- 3.3 vs. 17.9 +/- 2.8 bursts/min, P = 0.012), MSNA remained elevated during the EF phase in smokers (22.5 +/- 3.8 vs. 26.8 +/- 4.0 bursts/min, P = 0.28). Surprisingly, mean arterial pressure (MAP) was significantly lower during the ML phase than in the EF phase in both nonsmokers (P = 0.0080) and smokers (P = 0.0094). We conclude that smoking disrupts the ovarian pattern of SNS activity by preventing the normal fall in MSNA during the EF phase of the ovarian cycle. Such chronic alterations may contribute to the pathogenesis of cardiovascular risk in young smoking females.

Nicotine pretreatment increases dysphoric effects of alcohol in luteal-phase female volunteers

The present report shows that nicotine enhances some of alcohol’s positive and negative effects in women and that these effects are most pronounced during the luteal phase of the menstrual cycle. Ten low progesterone and 10 high progesterone/luteal-phase women received nicotine patch pretreatments (placebo or 21 mg) 3 hours before an alcohol challenge (0.4 g/kg). Subjective effects were recorded on mood adjective scales and the Addiction Research Center Inventory (ARCI). Heart rate and skin temperature were recorded. Luteal-phase women reported peak positive (e.g. “stimulated”) and peak negative effects (e.g. “clumsy”, “dizzy”) almost twice as great as low progesterone women.

Influence of phase-related variability in premenstrual symptomatology, mood, smoking withdrawal, and smoking behavior during ad libitum smoking, on smoking cessation outcome

Emerging evidence suggests that women have a more difficult time quitting smoking than men-possibly due, in part, to sex hormones. The present study characterized mood, premenstrual symptomatology, and smoking withdrawal, as well as smoking behavior, in the follicular and luteal phases during ad libitum smoking in 25 women intending to quit. We also investigated the possible influence of phase-related variability in these measures on likelihood of study adherence and smoking cessation. We found that premenstrual symptomatology, as well as some measures of mood and smoking withdrawal, were significantly higher during the luteal phase than in the follicular phase. Cigarettes/day did not vary by menstrual cycle phase. Phase-related variability in premenstrual symptomatology [F(3, 20)=2.82, p=0.0650)] and urge to smoke [F(2, 21)=4.85, p=0.0186)] were associated with relapse. These data support the inference that sex hormones influence smoking cessation outcome. This knowledge may contribute to the development of more rational and effective smoking cessation interventions for women.

The effect of food deprivation on cigarette smoking in females

Food deprivation is associated with increased self-administration of nicotine and other substances in laboratory animals, although little is known about the effects of food deprivation on substance use in humans. A within-subjects design was utilized to test the primary hypotheses that smoking rate and expired carbon monoxide (CO) levels would be greater among 15 female participants following a 24-hour fasting period than when participants were not food-deprived. Food-deprived participants were also expected to endorse greater negative mood, smoking urges, and pleasure from smoking, as well as less positive mood. Analyses indicated that CO levels were significantly greater in the food-deprived condition than in the non-deprived condition (p=.05), although no differences were found in the number of cigarettes smoked during the laboratory session. Participants reported significantly lower Vigor-Activity in the food-deprived condition (p=.02). No differences were found between conditions in urges to smoke or pleasure from smoking. Findings suggest that nicotine intake may increase among females during acute food deprivation.

Menstrual cycle phase at quit date predicts smoking status in an NRT treatment trial: a retrospective analysis

BACKGROUND AND OBJECTIVE

The deleterious health consequences of smoking are even more severe for women, yet ironically, they have more difficulty quitting than men. Identifying relapse predictors for women and implementing strategies to increase their chances of successfully quitting and remaining abstinent are important goals. Clinicians and researchers suggest that women could achieve greater success in smoking cessation interventions if the initial quit attempt coincided with the follicular phase (i.e., preovulatory phase) of their menstrual cycle (MC) rather than the luteal phase (i.e., premenstrual). However, no experimental data have been published to support this claim. Our objective was to determine whether MC phase affected smoking status in premenopausal female smokers participating in a smoking cessation treatment trial.

METHODS

Data from 102 treatment-seeking smokers who participated in an 8-week nicotine replacement therapy (NRT) plus behavioral intervention smoking cessation study were examined retrospectively. NRT began the day subjects attempted to quit smoking (quit date). For analyses, smokers were grouped according to sex, and women were subdivided by MC phase at quit date into follicular (FF, days 1-14, n = 16) and luteal (LF, days 15-30, n = 21) groups.

RESULTS

Smoking status was examined on the third day after the quit date (day 3) and at 1 week posttreatment (week 9). On day 3, 52% of LFs reported smoking compared with 19% of FFs (p < 0.04), and at week 9, 71% of LFs reported smoking compared with 31% of FFs (p < 0.02). In a comparison group of men (n = 65), 25% were smoking at day 3 and 68% at week 9. Self-report at week 9 was verified by urine cotinine levels.

CONCLUSIONS

These data support the supposition that better treatment outcomes can be achieved by scheduling quit dates to coincide with the follicular phase of the MC in female smokers.

Menstrual phase effects on smoking relapse

AIMS

To examine if menstrual phase affects relapse in women attempting to quit smoking.

DESIGN

An intent-to-treat randomized smoking cessation trial where women were assigned to quit smoking in either the follicular (F) or luteal (L) menstrual phase and were followed for up to 26 weeks. They were assessed for relapse by days to relapse and relapse phase to determine if those who begin a quit attempt during the F phase were more successful than those who begin during the L phase.

SETTING

Tobacco Use Research Center, University of Minnesota, Minneapolis, Minnesota.

PARTICIPANTS

A total of 202 women.

MEASUREMENTS

Latency to relapse from continuous and prolonged abstinence, point prevalence, phase of relapse, first slip within the first 3 and 5 days post-quit date, subject completion rates and symptomatology (i.e. withdrawal and craving).

FINDINGS

The mean days to relapse from continuous abstinence and relapse from prolonged abstinence for the F group were 13.9 and 20.6 days, respectively, and 21.5 and 39.2 days, respectively, for the L group. Using point prevalence analysis at 14 days, 84% of the F group had relapsed compared with 65% of the L group [chi(2)=10.024, P=0.002; odds ratio (OR) = 2.871, 95% confidence interval (CI), 1.474-5.590]. At 30 days, 86% of the F group relapsed, compared with 66% of the L group (chi(2)=11.076, P=0.001; OR=3.178, 95% CI, 1.594-6.334).

CONCLUSION

Women attempting to quit smoking in the F phase had less favorable outcomes than those attempting to quit in the L phase. This could relate to ovarian hormones, which may play a role in smoking cessation for women.

Effect of the menstrual cycle on pain experience associated with periodontal therapy. Randomized, pilot study

OBJECTIVES

The aim of this pilot cross-over study was to compare preliminarily the pain perception of female patients undergoing periodontal debridement during menstrual or pre-menstrual phases (peri-menstrual period) with that observed during mid-menstrual phase (post-menstrual period).

MATERIALS AND METHODS

Twenty women with moderate-to-advanced chronic periodontitis and regular menstrual cycles were asked to complete Corah's Dental Anxiety Scale (DAS) during the first debridement visit. Patients were randomly assigned to receive their first debridement visit during either their peri-menstrual or post-menstrual period. Debridement was performed in bilateral quadrants of patients during the periods. Pain levels for each quadrant were assessed with a Visual Analogue Scale (VAS), after each debridement visit.

RESULTS

There was no significant correlation of order of treatment in the intensity of perceived pain during the periods (p<0.05). The median VAS scores were 22.0 and 15.2 mm in the peri-menstrual and the post-menstrual period, respectively. Increase in pain perception among females during their peri-menstrual period was significantly greater than their post-menstrual period (p<0.05).

CONCLUSION

No clinical conclusions can be drawn at this stage as this pilot study did not have a sufficiently broad population to generalize these observations to all female periodontal patients. Providing clinicians with information about patients' menstrual cycle during debridement can alter the pain experience.

Influence of menstrual cycle on cytochrome P450 2A6 activity and cardiovascular effects of nicotine

BACKGROUND AND OBJECTIVES

The phase of the menstrual cycle has been reported to affect frequency of smoking, withdrawal symptoms, and the likelihood of smoking cessation in women. Cytochrome P450 (CYP) 2A6 is primarily responsible for the metabolism of nicotine. Our objective was to evaluate the effect of the phase of the menstrual cycle on the activity of CYP2A6 and the cardiovascular effects of nicotine.

METHOD

Eleven healthy, nonsmoking women received a 30-minute combined infusion of deuterium-labeled nicotine and cotinine (0.5 microg . kg(-1) . min(-1) of each compound) during the midfollicular and midluteal phases of the menstrual cycle. Nicotine and cotinine pharmacokinetic parameters and plasma adrenocorticotropic hormone (ACTH), epinephrine, and norepinephrine responses were measured over time.

RESULTS

There were no biologically or statistically significant differences in the comparison of menstrual cycle phases with regard to the pharmacokinetics of nicotine and cotinine. Nicotine clearance was 1000 +/- 315 mL/min and 1047 +/- 271 mL/min in the follicular and luteal phases, respectively (geometric mean ratio, 1.06; 90% confidence interval, 0.87-1.29). Cotinine clearance was 44 +/- 20 mL/min and 55 +/- 42 mL/min in the follicular and luteal phases, respectively (geometric mean ratio, 1.13; 90% confidence interval, 0.90-1.41). Nicotine infusion increased blood pressure, heart rate, and epinephrine concentrations. There were no differences in catecholamine, ACTH, or hemodynamic responses to nicotine infusion between menstrual cycle phases, although norepinephrine concentrations were constantly higher in the luteal phase compared with the follicular phase.

CONCLUSIONS

CYP2A6 activity is not affected by menstrual cycle phase, and it is unlikely that menstrual cycle-related smoking habits of women are determined by changes in nicotine pharmacokinetics. The effects of nicotine on plasma ACTH and catecholamine levels and hemodynamic parameters are not altered by menstrual cycle phase in healthy, nonsmoking women.

Progesterone treatment during the early follicular phase of the menstrual cycle: effects on smoking behavior in women

The goals of this study were (1) to examine the feasibility of administering progesterone to women during the early follicular phase when the endogenous estradiol and progesterone levels are low, and (2) to investigate the effects of oral progesterone treatment on smoking behavior in female smokers. Twelve subjects had two experimental sessions, within 3-9 days after the beginning of their menses. In each experimental session, subjects received a single 200-mg dose of progesterone or placebo, orally. Two and a half hours after the medication treatment, subjects were assessed for subjective response to two puffs of a cigarette and then started the self-administration period in which they had the option to exchange their token for two puffs of cigarette, 15 min apart. Subjects had low levels of estradiol and progesterone before the first and second sessions. Plasma progesterone levels peaked in 2 h following progesterone treatment. Progesterone treatment attenuated the craving for and subjective effects from smoking. Under progesterone treatment, there was a trend for decreased smoking behavior. These preliminary results suggest that the early follicular phase of the menstrual cycle may be a useful interval to investigate the effects of exogenous progesterone in female smokers. The effects of progesterone on nicotine dependence need to be studied further.

Smoking behavior, dysphoric states and the menstrual cycle: results from single smoking sessions and the natural environment

A 2-way factorial repeated measures design examined the effects of menstrual cycle phase and smoking on: 1) smoking behavior, 2) mood state, 3) nicotine withdrawal symptomatology, and 4) menstrual symptomatology. Female smokers, aged 20-39, were followed for two consecutive menstrual cycles with two data collection sessions per cycle, which were conducted in the University's General Clinical Research Center (GCRC). Participants were randomly assigned to order of smoking condition, which included: 1) smoking ad libitum, and 2) 24-hour abstinence prior to data collection. Data were collected in the mid-to-late follicular (MLF) phase (between days 6 through to 11) and the four days prior to menses in late luteal (LL) phase. Participants completed the Profile of Mood States and Menstrual Symptom Severity List and recorded daily cigarette smoking rate in the natural environment during MLF and LL phases. Nicotine boost and carbon monoxide (CO) boost were measured and the Shiffman-Jarvick Tobacco Withdrawal Questionnaire was administered during GCRC data collection sessions. Results indicated that subjects smoked more cigarettes per day during the LL phase and CO boost was greater during MLF. No difference was noted in nicotine boost by condition or phase. No difference in mood state was noted by either condition or phase. Withdrawal symptomatology and craving for cigarettes were increased after 24 hours of abstinence. No difference was noted in menstrual symptoms by condition or phase. Further investigations are still needed to characterize the importance of cycle phase in the design of smoking cessation interventions for women of reproductive age.

Effects of menstrual phase and smoking abstinence in smokers with and without a history of major depressive disorder

Although considerable progress has been made towards understanding the role of menstrual cycle phase in smoking, little is known about the possible effects of menstrual phase upon nicotine intake, withdrawal symptomatology, and craving in women with psychiatric cofactors. Fourteen women with and without a history of Major Depressive Disorder (MDD) were studied during five biologically-confirmed phases over the course of one menstrual cycle: smoking logs, salivary cotinine, and ratings of craving and withdrawal were collected daily. During a second cycle, subjects remained abstinent for 3 consecutive days during the postmenses and premenstrual phases. Although a significant omnibus F-test emerged for cigarettes per day across phases during ad libitum smoking, only trends were observed post hoc and supported midcycle rather than premenstrual elevations. There were no significant phase differences for cotinine. Withdrawal symptomatology was markedly elevated during smoking abstinence and in women with a history of depression. but showed no evidence of phase effects. Thus, the hypothesis that depressed individuals would be differentially affected by phase and abstinence was not strongly supported by our results, though overall elevations emphasize the need for special attention to withdrawal severity in this population. Craving was significantly elevated during smoking abstinence and was significantly higher during postmenses, consistent with the midcycle elevation in smoking rate, but showed no group differences. Our findings overall lend little support for the need to control for menstrual phase under conditions of ad libitum smoking. The strong association of self-reported menstrually related dysphoria during abstinence with both craving and withdrawal symptoms, however, is consistent with an exacerbation of smoking abstinence effects in women with severe menstrual symptomatology.

Tobacco withdrawal in women and menstrual cycle phase

Because negative mood is a characteristic of both tobacco withdrawal and menstrual discomfort, withdrawal may vary by menstrual cycle phase. Tobacco withdrawal, mood, and menstrual discomfort were assessed in premenopausal women who quit smoking during either the follicular (Days 1-14 postmenstrual onset; n = 41) or luteal (Day 15 or longer postmenstrual onset; n = 37) phase of the menstrual cycle and maintained biochemically verified smoking abstinence during the postquit week. Women quitting during the luteal phase reported significantly greater increases in tobacco withdrawal and self-reported depressive symptoms than women quitting during the follicular phase. These results indicate that selecting a quit-smoking day early in the follicular phase may attenuate withdrawal and negative affect in premenopausal female smokers.

Sex differences in nicotine effects and self-administration: review of human and animal evidence

Although both the human and animal literatures are notable for the general lack of attention paid to possible sex differences in drug self-administration behavior, evidence is accumulating to suggest that males and females may differ in factors that maintain tobacco smoking or nicotine self-administration. Self-administration of nicotine per se may be less robust in women, and women are less sensitive than men to some effects of nicotine that may be reinforcing. Compared to men, smoking behavior of women may be influenced more by non-nicotine stimuli associated with smoking, suggesting greater conditioned reinforcement of smoking in women. Moreover, nicotine replacement, the current standard treatment for smoking cessation, is sometimes less effective in women, further suggesting the need for greater consideration of non-nicotine factors that may maintain women's smoking. Very recent research on rats also indicates sex differences in nicotine self-administration. However, these differences are complex and suggest that nicotine-seeking behavior is composed of several components, including hedonic, incentive-motivational, and conditioning effects; males and females may differ in one or more of these components. Menstrual or estrous cycle phase effects on the maintenance of nicotine self-administration are not particularly apparent in humans or animals, although cycle phase may influence other stages of dependence (e.g., withdrawal symptoms during cessation). Future research should evaluate further the consistency of results across human and non-human species, identify the conditions and procedures under which sex differences are observed, and elucidate the specific components of reinforcement that may differ between males and females. Studies also should examine the possible generalizability of these sex differences to other drugs of abuse. Identification of specific factors responsible for these sex differences may lead to improved interventions for smoking cessation and other substance abuse in women.

History of depression and subsyndromal depression in women smokers

While Major Depressive Disorder (MDD) is associated with difficulty quitting smoking, few studies have examined the role of subsyndromal depression (SubD). We examined pretreatment differences in smoking, weight concerns, and negative affect among three groups of women (N = 281) enrolling in a smoking cessation program who responded to a self-report questionnaire about the lifetime presence of MDD symptoms: self-report positive for MDD, self-report positive for SubD, and self-report negative for depression (fulfilling either DSM-III-R symptom or duration criteria, but not both). Compared to MDD Subjects (Ss), SubD Ss were more likely to report eating disordered behaviors. Compared to Non-Depressed (Non-Dep) Ss, SubD Ss initiated smoking earlier, and reported greater previous withdrawal symptoms, more eating disordered behaviors, and higher anxiety, depression, and stress. Compared to Non-Dep Ss, MDD Ss reported a greater smoking rate during their heaviest usage period, greater previous withdrawal symptoms, lower self-efficacy to manage food intake (especially during negative affect situations), and greater depression and anxiety. Many of these significant differences disappeared when SubD Ss were combined with Non-Dep Ss and compared with MDD Ss as is done traditionally. SubD does not appear to be on a continuum with Non-Dep and MDD groups, but rather warrants further investigation as a discrete subset of smokers. The implications for assessment and treatment are discussed.

Withdrawal and pre-menstrual symptomatology during the menstrual cycle in short-term smoking abstinence: effects of menstrual cycle on smoking abstinence

This study employs a rigorous inpatient laboratory setting to test the hypothesis that withdrawal symptomatology in short-term smoking cessation in women is increased in the late luteal phase when pre-menstrual symptomatology is the highest. Twenty-one female smokers with clinical, anatomical, and hormonal verification of their menstrual cycle phase were randomized to either a smoking abstinence group (n = 16) or a continued smoking group (n = 5). Participants were admitted to the General Clinical Research Center during alternate phases of their cycle for two 7-day admissions with a 1-month interim period when they resumed smoking. Dependent measures, i.e., Minnesota Nicotine Withdrawal Scale scores, Questionnaire on Smoking Urges scores and Pre-menstrual Assessment Form scores were collected during 2 days of baseline and 5 days of smoking deprivation. Smoking behavior was documented by self-report, breath CO levels and saliva cotinine measurements. Withdrawal symptomatology was not affected by menstrual cycle phase during short-term cessation in spite of increased pre-menstrual changes seen in the late luteal phase. In addition, no phase effect on smoking behavior was detected and cigarette consumption remained stable across the cycle in both groups. These results suggest that for some smoking cessation studies, complex strategies to control for menstrual cycle effects may not be necessary. However, Smoking Urges scores did suggest increased desire to smoke and desire to relieve negative affect in the late luteal phase when women have higher pre-menstrual symptomatology. This suggests women may have greater difficulty quitting smoking in late luteal phase, and it seems prudent to recommend that women quit during the follicular phase of their cycle.

Effects of menstrual phase on reactivity to nicotine

The possible impact of menstrual phase upon reactivity to nicotine was investigated in 12 healthy women smokers. Controlled doses of nicotine were administered via an intranasal aerosol delivery device to overnight-deprived women smokers in four hormonally verified menstrual phases. Physiological, biochemical, and subjective measures were collected. Cycle-related symptomatology differed significantly across phase, with lowest values during the mid-follicular phase. No significant differences were found for baseline variables, including withdrawal measures. Nicotine increment was stable across phase, confirming reliability of the dosing method. No significant menstrual phase differences were found for physiological, subjective, or biochemical responses to nicotine. Pending investigations conducted over longer intervals, in a wider variety of subjects; findings suggest that for this type of study, complex strategies to control for menstrual-cycle phase effects may be unnecessary.

Gender differences in the pharmacology of nicotine addiction

Smoking rates have declined in recent years less rapidly in women than in men. More adolescent girls than boys are currently smoking. Quitting smoking is reported in many studies to be more difficult in women than in men. These observations suggest that there may be gender differences in the nature of nicotine addiction. Gender differences in various pharmacological processes involved in nicotine addiction are reviewed. Women take in less nicotine from smoking per cigarette than men but, because of slower metabolism, nicotine levels in the body for a given number of cigarettes per day are similar in male and female smokers. Women tend to be less sensitive to the discriminative effects of nicotine and tend to regulate nicotine intake less precisely than men. On the other hand, women appear to be more sensitive to the effects of nicotine in reducing negative affect and reducing body weight. There is a strong association between depression and smoking, and this association appears to be stronger in women than in men. Women tend to respond more to environmental cues associated with smoking than do men. Thus, several lines of evidence suggest that nicotine addiction is different in women than in men. Understanding the basis for gender differences may be of utility in individualizing and optimizing smoking cessation therapy.

Gender differences in the outcome of an unaided smoking cessation attempt

There is conflicting evidence concerning gender differences in success at quitting smoking. Information is especially lacking regarding gender differences among unaided quitters who make up the vast majority of those attempting to quit. One hundred thirty-five smokers who made an unaided attempt at quitting were interviewed before quitting and were followed for 1 year after cessation. Relapse rates were extremely high both for men and women, with 62% of participants returning to regular smoking within 15 days after cessation. Women and men were equally likely to maintain short-term abstinence (through 15 days), but women were more than three times as likely to relapse subsequently. Nine percent of men, but no women, had biochemically verified sustained abstinence throughout the 1-year follow-up period. For both men and women, any smoking after the quit attempt inevitably led to full-blown relapse. Most participants resumed regular smoking within 24 hours after the first episode of smoking. Gender differences were observed for several variables related to smoking history, demographics, social support, perceived stress, and motivational factors, but these differences did not explain the increased risk of relapse for women. Our results clearly indicate that women are less likely than men to maintain long-term smoking abstinence following an unaided quit attempt, but reasons for this gender difference need further exploration.

Symptomatology and energy intake during the menstrual cycle in smoking women

This study extends our understanding of smoking behavior, withdrawal, and premenstrual symptomatology in smoking women, as well as energy intake as a function of cycle phase. Thirty-two women age 18 to 40 years, smoking ad lib, were followed for an average of two menstrual cycles with hormonal verification. Withdrawal and premenstrual symptomatology as well as energy intake were reported during the follicular (F), luteal (L), and late luteal (LL) cycle phases. Both premenstrual symptomatology and withdrawal symptomatology were higher during the LL phase. Subject response on measurements of craving, irritability, restlessness, increased appetite, and depressed mood tended to be higher in the LL phase. Energy intake did not vary as a function of cycle phase. Participants perceived that they smoked more and had increased appetite in the LL phase but related measurements did not confirm this. Premenstrual and withdrawal symptoms are highly correlated and one needs to be cautious in interpreting cycle effects on withdrawal. Overall symptomatology seems to be lower during the F phase, indicating that this may be a more opportune time for women to quit smoking.