Levonorgestrel
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Depressive disorder with panic attacks: case report A 41-year-old woman developed depressive disorder with panic attacks secondary to levonorgestrel-releasing intrauterine system (IUS) as long-term contraception therapy. The married woman with 4 children, electively underwent levonorgestrel-releasing IUS [Mirena] placement 8 years after the birth of her fourth child. She had no history of psychiatric disorders or any other general medical condition. Five years after the implantation, a second levonorgestrel-IUS was inserted. The removal of the previous levonorgestrel-IUS and the insertion of the new one was performed on the same day. Within the first week of inserting the second device, she experienced an increased psychomotor restlessness, which was more prominent in the evening and during night [exact time to reaction onset not stated]. She also experienced episodes of tachycardia and irregular heartbeat. Her condition worsened in the following 6 months, and she developed suicidal ideations, anxiety in the night, sleep disturbances and emotional lability. She also reported development of somatic complaints such as pelvic pain with variable intensity, shivering and hot flashes. Repeat medical examinations including ECG, blood tests (thyroid hormones, glucose, infection parameters, liver and kidney values, electrolytes, differential blood count), failed to show any significant results. A cardiology examination (long-term ECG, exercise ECG and cardiac ultrasound) showed supraventricular extrasystoles without any other pathological findings. Despite all tests showing normal results, she continued to worry about her well being. Her anxieties continued to worsen and her frequency of panic attacks increased including the fear to faint or even to die, which led to an emergency call. Several gynaecological examinations led to the presumptive diagnosis of premenopausal syndrome in the context of early menopause; however, due to normal somatic examinations and continued worsening of her symptoms in the previous 3 years after the placement of levonorgestrel, a mental origin was considered. Due to suspected diagnosis of depressive and anxiety disorder, the woman’s treatment was started with lorazepam, mirtazapine and sertraline (treatment started by her family physician). With the treatment, she reported a minor improvement in sleep disturbances and remission of panic attacks, but higher levels of anxiety, rumination, depressed mood, inner restlessness and her emotional lability persisted. Thereafter, she consulted a psychiatrist, and received supportive psychotherapy for five sessions. At this time, psychometric subjective measures of depressive mood according to the Beck depression inventory (BDI) showed a sum-score of 42, which indicated a severe depressive syndrome. Then she was informed regarding the potential association between changes in mood and the use of hormonal contraceptives by the psychiatrist. The psychiatrist also recommended the removal of the levonorgestrel-IUS. The gynaecologist initially denied any a
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