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Patients and clinicians alike want to know if stress causes infertility. Stress could impair with reproductive function by a variety of mechanisms, including compromise of ovarian function, spermatogenesis, fertilization, endometrial development, implantation, and placentation. Herein we focus on the pathogenesis and treatment of stress-induced anovulation, which is often termed functional hypothalamic amenorrhea (FHA), with the objective of summarizing the actual knowledge as a clinical guide. FHA is a reversible form of anovulation due to slowing of gonadotropin-releasing hormone pulse frequency that results in insufficient pituitary secretion of gonadotropins to support full folliculogenesis. Importantly, FHA heralds a constellation of neuroendocrine alterations with health concomitants. The activity of the hypothalamic-pituitary-adrenal axis is increased in women with FHA and this observation supports the notion that stress is the cause. The extent of reproductive suppression relates to individual endocrinological and physiological sensitivity to stressors, both metabolic and psychogenic, and chronicity.

Observational studies have suggested that arterial distensibility decreases during menopause; however, its relationship with hormone therapy use remains controversial. We prospectively studied distensibility and hormone therapy use at different menopause stages.One hundred sixty-one women (aged between 42 and 61 y) without cardiovascular disease underwent carotid artery measurements by ultrasound to calculate distensibility index at baseline and 3 years later. Menopause stage was classified at each visit as premenopausal, perimenopausal, and postmenopausal. Across 3 years of prospective observation, women were classified as remaining premenopausal, remaining postmenopausal, or transitioning (defined as change from premenopausal to perimenopausal, from premenopausal to postmenopausal, from perimenopausal to perimenopausal, or from perimenopausal to postmenopausal).Distensibility declined across time at all menopause stages (P0.0001). Compared with postmenopausal women, premenopausal and transitioning/no hormone therapy women had more than twice the decline in distensibility index (P = 0.06 and P = 0.016, respectively), whereas transitioning/hormone therapy women did not differ in distensibility decline (P = 0.28). In a multivariate model, change in systolic blood pressure (P0.0001) and change in pulse pressure (P = 0.004) were independent predictors of distensibility index change and served as effect modulators. In an adjusted model, women in the premenopausal and transitioning/no hormone therapy groups had a significantly faster decline in distensibility index (P = 0.002 and P = 0.001, respectively) compared with postmenopausal women, whereas the transitioning/hormone therapy group did not (P = 0.21).These findings confirm that the menopausal transition is associated with reduced vascular compliance. Hormone therapy is associated with better arterial distensibility only during the menopausal transition. Additional prospective studies are needed to confirm these findings and to determine whether hormone therapy use beyond the menopausal transition is related to distensibility.

Changes in cognitive function in women with breast cancer are frequently attributed to adjuvant therapy.1–3 The basis for these changes is likely to be multifactorial and is not completely understood. Moreover, results of longitudinal studies that include pretreatment cognitive assessments indicate that, before the start of adjuvant therapy, some women with breast cancer perform more poorly in cognitive measures than their healthy counterparts, suggesting that other factors influence pretreatment cognition.3–6 Multiple factors may predict pretreatment cognitive function in women with breast cancer, including their lifetime exposure to hormones.7 Substantial biological evidence indicates that estrogen has a positive influence on brain functioning, although, clinically, evidence for a relationship between estrogen and cognitive function is conflicting.8,9 The basis for this conflicting evidence may partly reflect a failure to take into account estrogen exposure factors during the course of a woman’s life. The influence of estrogen on the brain seems to begin prenatally and persists throughout a woman’s life.10 Endogenous factors (such as parity, age at menarche, and menopause or, collectively, the number of reproductive years) and exogenous factors (such as oral contraceptive use and hormone therapy [HT] use) all contribute to a woman’s lifetime exposure to hormones. Cognitive benefits of estrogen exposure may be specific for certain domains of cognitive function. Results of several studies suggest that greater lifetime exposure to estrogen is associated with better verbal memory in healthy women.11,12 Others have found that lifetime estrogen exposure is associated with better global cognitive function,13,14 psychomotor efficiency, concentration,15 and verbal attention14 in women. Although estrogen exposure seems to have cognitive benefits for women, exposure to hormones, such as estrogen, also places them at greater risk for breast cancer.16 However, a closer examination of specific factors that influence estrogen exposure during the course of a woman’s life may reveal that individual estrogen exposure factors have differential effects on cognitive function. Examining the influence of the differential effects of estrogen exposure on cognitive function may help to explain pretreatment cognitive function in women with breast cancer. Thus, we examined cognitive function in women with breast cancer before their initiation of systemic adjuvant therapy and compared them with healthy women to determine whether factors related to a lifetime exposure to hormones were associated with poorer cognitive function before therapy. We hypothesized that factors associated with less estrogen exposure (shorter reproductive life and parity) are associated with poorer cognitive function, particularly verbal memory, in women with breast cancer compared with healthy women and, conversely, factors associated with greater estrogen exposure (oral contraceptive use and HT use) are associated with better cognitive function, particularly verbal memory, in women with breast cancer.

Objective: Hormones have been implicated as modulators of cognitive functioning. For instance, results of our previous work in women with breast cancer showed that cognitive impairment was more severe and involved more memory domains in those who received adjuvant tamoxifen therapy compared with women who received chemotherapy alone or no adjuvant therapy. Recently aromatase inhibitors such as anastrozole have been used in lieu of tamoxifen for the adjuvant treatment of postmenopausal women with hormone receptor-positive, early-stage breast cancer. Plasma estrogen levels are significantly lower in women who receive anastrozole compared with those who receive tamoxifen. We hypothesized, therefore, that anastrozole would have a more profound effect on cognitive function than tamoxifen, a mixed estrogen agonist/antagonist. Design: To test this hypothesis we compared cognitive function in women with early-stage breast cancer who received tamoxifen with those who received anastrozole therapy in a cross-sectional study. We evaluated cognitive function, depression, anxiety, and fatigue in 31 postmenopausal women with early-stage breast cancer who were between the ages of 21 and 65 years and treated with tamoxifen or anastrozole for a minimum of 3 months. Results: The results showed that women who received anastrozole had poorer verbal and visual learning and memory than women who received tamoxifen. Conclusions: Additional, prospective studies are needed to validate and confirm the changes in cognitive function associated with hormone therapy for breast cancer.

BACKGROUND: Hyperandrogenism of ovarian origin is rare in postmenopausal women. However, there is evidence that the ovaries of postmenopausal women are active endocrine glands, secreting mainly androgens. CASE: A postmenopausal woman sought treatment for progressive hirsutism. Endocrine evaluation revealed androgen excess. Transvaginal ultrasound revealed enlarged ovaries. Hysterectomy and bilateral oophorectomy were recommended. However, surgery had to be withheld for 6 months while the patient recovered from an acute myocardial infarction. In the interim, the patient’s hyperandrogenemia was successfully treated with monthly injections of the gonadotropin-releasing hormone agonist (GnRH), leuprolide acetate. CONCLUSION: This report illustrates the potential for postmenopausal ovaries to become active androgen-secreting endocrine organs. It also demonstrates the efficacy of pharmacologic intervention for postmenopausal ovarian hyperthecosis when the patient is a poor surgical candidate.

Many forms of stress, including psychosocial stress, may be associated with reproductive dysfunction. Women seeking treatment for infertility often have been subjected to multiple stressors. The authors have developed an experimental primate model of hypothalamic amenorrhea. Combining mild psychosocial stress with a mild diet and moderate exercise suppresses reproductive function in this model. Because serotonergic activity is decreased in persons who are inordinately sensitive to stress, a study was planned to determine whether differences in endogenous function of the central serotonergic system can be found in stress-sensitive and stress-resistant female cynomolgus macaques. Sedated monkeys previously categorized as highly stress-resistant (HSR, normal menstrual cyclicity through 2 stress cycles), medium stress-resistant (MSR, ovulatory in only the first cycle), or stress-sensitive (SS, anovulatory when first exposed to stress) were challenged with an intravenous dose of 5 mg/kg of the serotonin-releasing drug fenfluramine. The hypothesis was that SS animals would have lower levels of central serotonergic activity. Thyrotropin-releasing hormone (TRH) was administered to control for differences in pituitary stores of prolactin or corticotropin-releasing factor (CRF) to control for low levels of ACTH. Release of prolactin in response to fenfluramine was significantly greater in the HSR animals than in the MSR and SS groups. Cortisol responses to fenfluramine were higher in the SS group than in either group of stress-resistant animals. Similar responses to fenfluramine were no longer evident after stimulation with TRH combined with CRF. These studies in macaques indicate differing reproductive hormone responses to moderate stress. Stress sensitivity correlates with prolactin secretion in response to fenfluramine, which promotes the release of serotonin. Highly stress-resistant animals have higher endogenous serotonin levels than do stress-sensitive animals in the absence of stress. Whether this reflects secretion of ovarian steroids, social status, or genetic predisposition remains to be determined.

Advances in our understanding of the physiological mechanisms subserving reproduction and those mediating responses to stress now permit us to understand in detail at least one mechanism by which stress compromises fertility. In women, stress, as evidenced by an increase in cortisol secretion, suppresses hypothalamic gonadotropin-releasing hormone (GnRH) input to the pituitary-ovarian axis. If the decrement in GnRH drive is chronic, anovulation results. Episodic decrements in the GnRH pulse generator likely result in luteal inadequacy or oligo-ovulation. The more complete the suppression of GnRH, the more likely is the reproductive compromise to be clinically recognizable. Profound and persistent loss of GnRH input manifests as amenorrhea, whereas episodic or less profound interruptions in GnRH secretion can be clinically occult and present only as decrements in luteal phase progesterone secretion by the corpus luteum in the face of preserved menstrual cycle intervals, i.e., so-called luteal phase defects. Recognition of stress-induced compromise of ovarian function expands therapeutic options because, at least in theory, stress management and reduction will lead to return of GnRH drive, resumption of ovulation and menses, and restoration of fertility.

While the relation between the onset of menopause and accelerated cardiovascular risk has been extensively studied, little information exists on the relationship of the menopausal transition and the development of preclinical atherosclerosis in women. We hypothesized that transition to menopause would be associated with a higher rate of progression of preclinical atherosclerosis. Methods: We evaluated 203 women (131 postmenopausal, 20 perimenopausal, and 52 premenopausal at entry) undergoing carotid intimal-media thickness (cIMT) measurement in the LAAS study, a prospective cohort study that included women aged 45– 60 years at entry without diagnosed cardiovascular disease who underwent three measurements (baseline, 1.5 and 3 year followup). cIMT was measured bilaterally in two body positions (lateral and supine), and average thickness over a 1 cm segment of the distal wall 25 mm proximal to the bulb was measured using automated edge-tracking software. Results: The mean age was 52±4 years, mean body mass index was 27.2±5.8, and 49% were non-white. At entry, 53% had hypertension, 3% diabetes, 16% were current smokers. Age-adjusted cIMT progression rate was similar among pre-, peri- and postmenopausal women (9±15 μ/yr) at entry, and similar among women who remained premenopausal (n=21) compared to those that transitioned to menopause (n=51) and to those who remained postmenopausal (n=131) during the observation period. Of the 51 transitioning women, age was not related to rate of cIMT progression. However, the rapidity of menopausal transition was related to the rate of IMT progression: women transitioning from pre to postmenopause within the 3 year period had a higher rate of cIMT progression compared to women with a slower transition (progressing from pre- to perimenopause, or from peri- to postmenopause, p=0.03). Additional adjustment of these results for systolic blood pressure and BMI did not alter the results. Conclusions: Among women undergoing repeated cIMT measurement in the LAAS, a more rapid menopausal transition (from pre- to postmenopause within 3 years) was associated with a higher rate of preclinical atherosclerosis progression; alternatively, menopausal status itself did not appear to be associated with rate of progression.

Objective To determine whether serum levels of vascular permeability factor (VPF) are elevated in patients with ovarian hyperstimulation syndrome (OHSS) and to determine if luteinizing granulosa cells may be a source of VPF. Design Prospective observational study. Setting University IVF and GIFT program. Patients Eight consecutive IVF and GIFT patients at high risk for OHSS. Main Outcome Measures Vascular permeability factor concentration in serum and follicular fluid. Results Serum VPF was significantly higher (15.2 ± 4.0 pM; mean ± SEM) on day +14 in the group who developed severe OHSS compared with those who did not. Follicular fluid VPF (171.5 ± 18.5 pM) was approximately 100-fold greater than serum (1.7 ± 1.3 pM) or peritoneal fluid (2.5 ± 1.3 pM) 36 hours after hCG administration. Conclusion Vascular permeability factor is elevated in patients with severe OHSS and the ovary may be a source of VPF secretion.

A standard infertility evaluation consists of a semen analysis, hysterosalpingogram, post-coital test, endometrial biopsy and laparoscopy. Although these tests are well grounded in clinical experience, information on their ability to discriminate between fertile and infertile couples is limited. In this study, we performed standard infertility tests plus two others--sperm antibodies and cervical culture for Mycoplasma hominis and Ureaplasma urealyticum--on fertile and infertile couples. Women in the fertile group were selected from those who had delivered a child within the previous 2 years and who were scheduled for a laparoscopic tubal ligation. Women in the infertile group were selected from those presenting for an infertility evaluation (mean duration of infertility 4.2 years), and they were matched by age (+/- 3 years) and race with fertile subjects. Subjects were recruited from both private and clinic patients. A total of 64 couples (32 matched pairs) completed the evaluation. At least one 'abnormal' infertility test was found in 69% of fertile and 84% of infertile couples. With the exception of tubal damage and endometriosis, which as expected were more common in infertile couples, no significant differences between groups for remaining infertility factors could be demonstrated. Despite the small size of the current study, these results confirm the feasibility and importance of comparisons of the prevalence of infertility factors in fertile and infertile couples.