Lithium and valproate serum level fluctuations within the menstrual cycle: a systematic review

The impact of menstrual cycle on the pharmacokinetics of antiseizure medications and lithium: a systematic review and meta-analysis

INTRODUCTION

Our aim was to quantify the impact of menstrual cycle phases on the pharmacokinetics of antiseizure medications (ASM) and lithium.

METHODS

A systematic literature search was conducted in PubMed/EMBASE in March 2024 for studies comparing levels of ASM and/or lithium in the early follicular and luteal phase. Concentration ratios between the follicular and the luteal phase were calculated. We performed a random-effects meta-analysis calculating between-timepoint differences in plasma concentration mean differences (MDs) and 95% confidence intervals (95% CIs). Subgroup analyses included cohorts stratified by the occurrence of catamenial exacerbation. Study quality was assessed using the ClinPK guidelines.

RESULTS

Fifteen studies investigating six ASM and lithium in 224 subjects were included. The highest concentration ratio was reported for carbamazepine (1.27, range 0.89-2.13) with an MD of 0.57 μg/mL, 95% CI: 0.41 to 0.72. Phenytoin concentration fluctuations were larger in subjects with (MD -3.51 μg/mL, 95% CI = -4.97 to -2.06) vs. without catamenial exacerbations (MD -1.18 μg/mL, 95% CI = -2.51 to 0.14, p = 0.02). Study quality was acceptable with an average rating score of 13.1.

CONCLUSIONS

Data do not suggest major changes in ASM pharmacokinetics across the menstrual cycle. Participants with vs. without catamenial exacerbation had larger phenytoin concentration decreases in the early follicular compared to the luteal phase.

PROTOCOL REGISTRATION

www.crd.york.ac.uk/prospero identifier is CRD42024527321.

Changes in Psychotropic Drug Concentrations Across the Menstrual Cycle: A Pilot Study

BACKGROUND

The escalating prescription of psychopharmacological medications to women of reproductive age underscores the growing significance of sex-specific variations in pharmacotherapy. Despite this, clinical trials have largely overlooked these differences. Preliminary data indicate sex-specific variations in the neurobiology of affective disorders and in the metabolism, pharmacodynamics, and kinetics of therapeutic drugs. This underscores the imperative for a more nuanced exploration of menstrual cycle-dependent fluctuations in psychotropic drugs. This pilot study aimed to investigate drug and hormone fluctuations in female patients with affective disorders, aiming to enhance comprehension of the interplay between cycle-related hormone fluctuations and pharmacokinetics. The ultimate goal is to facilitate more effective and safer pharmacological therapy in the future.

METHODS

Blood samples were collected from 27 patients and 27 age-matched control participants at 3 distinct time points (early follicular phase, ovulation, and late luteal phase) during each menstrual cycle. Depressive and manic symptoms were assessed, and hormone concentrations were measured in the entire sample, while drug concentrations were assessed solely in the affective disorder sample using mass spectrometry.

RESULTS

Significant variations in drug concentration were observed throughout the menstrual cycle for bupropion, with a trend toward altered concentration for venlafaxine. Moreover, notable differences in hormone concentrations were identified between patients and controls, even after accounting for the impact of contraceptive use, diagnoses, and medication.

CONCLUSIONS

This pilot study reinforces previously reported data, underscoring the significance of sex-specific pharmacological therapy approaches. It provides further evidence supporting the interaction among sex hormones, drugs, and symptoms of affective disorders.

Premenstrual exacerbation of mental health disorders: a systematic review of prospective studies

Mental health disorders can be exacerbated during periods of hormonal fluctuation (e.g. pregnancy, menopause), and the risk factors for sensitivity to these fluctuations are similar to those of mental disorders (e.g. trauma). However, the extent to which hormonal fluctuations during the menstrual cycle impact symptoms of preexisting mental disorders remains unclear. Prospective methodology is considered the gold standard for measuring symptoms across the menstrual cycle. Thus, the aim of the review was to address this knowledge gap by summarising all available studies prospectively measuring symptoms of mental disorders across the menstrual cycle. A systematic review with narrative synthesis was conducted; meta-analysis was precluded due to methodological heterogeneity of included studies. Electronic databases MEDLINE, Embase, PyschINFO and CINAHL were systematically searched from inception. Risk of bias for individual studies was assessed using a modified version of the Newcastle-Ottawa Scale. The search identified 629 studies from which 35 met inclusion criteria. There was clear evidence of symptom exacerbation during the perimenstrual phase for psychotic disorders, panic disorder, eating disorders, depression and borderline personality disorder. Less consistent evidence was found for anxiety, and a different pattern of symptom exacerbation was observed in bipolar disorder. Sample size and methodology varied considerably amongst studies. Overall, there was mixed evidence for perimenstrual exacerbation across mental disorders, which could be partly explained by methodological limitations of the studies. However, hormonal fluctuations during the menstrual cycle may exacerbate psychiatric symptoms in a subgroup of individuals who are hormone sensitive.

Premenstrual Exacerbations of Mood Disorders: Findings and Knowledge Gaps

PURPOSE OF REVIEW

In contrast to premenstrual dysphoric disorder (PMDD), premenstrual exacerbations (PMEs) of ongoing mood disorders are understudied. The aim of this review is to describe diagnostic issues, epidemiology, underlying mechanisms, and treatment for PME in unipolar depression and bipolar disorder, and to discuss clinical and research implications.

RECENT FINDINGS

Community-based and clinical studies estimate that in women with mood disorders around 60% report PME, while some women with bipolar disorder also show symptom exacerbations around ovulation. In general, PME predicts a more severe illness course and an increased burden. While heightened sensitivity to fluctuations of sex hormone levels across the menstrual cycle appears to contribute to PME and PMDD, the overlap of their underlying biological mechanisms remains unclear. Beneficial treatments for PMDD show less or no efficacy in PME. Pharmacological treatments for PME in mood disorders predominantly seem to profit from adjustable augmentation of treatment dosages during the luteal phase for the underlying disorder. However, the evidence is sparse and mainly based on earlier small studies and case reports. Previous research is mainly limited by the lack of a clear differentiation between PME and PMDD comorbidity with mood disorders. More systematic research with uniformly defined and prospectively assessed subgroups of PME in larger epidemiological and clinical samples is needed to receive reliable prevalence estimates and information on the clinical impact of PME of mood disorders, and to uncover underlying mechanisms. In addition, larger randomized controlled trials are warranted to identify efficacious pharmacological and psychotherapeutic treatments for affected women.