Current management of the amenorrhea-galactorrhea syndrome

Management of the amenorrhea-galactorrhea syndrome has changed considerably in the last 5 years. Better understanding of the neuroendocrine physiology of the central nervous system in general, and of the hypothalamic-pituitary region in particular, have contributed significantly to our understanding of the pathophysiology of this syndrome. Greater awareness by physicians, improved neuroradiologic techniques, and the development of immunoassays for prolactin have markedly improved our diagnostic abilities. Many more patients are being diagnosed as having a pituitary tumor. The recent introduction of microneurosurgical techniques and the new medications (ergolines) are changing the treatment of this syndrome. Women in the childbearing age--who are affected most often--can expect successful treatment in the majority of cases with resumption of normal menstrual function and fertility. However, certain risks are still posed, particularly during pregnancy. In spite of improved diagnosis and treatment, the natural history of prolactin-secreting pituitary tumors and the long-range effects are still not fully appreciated. More experience in time will be needed before the indications for and the efficacy of various treatment regimens are fully known.     

Corticosteroids, pregnancy, and HELLP syndrome: a review

Corticosteroids are potent antiinflammatory and immunosuppressive drugs, which are used in the treatment of a wide range of medical disorders. During pregnancy, several corticosteroids are administered for maternal as well as fetal reasons. Prednisone and prednisolone show limited transplacental passage and are thus used for treatment of maternal disease. Dexamethasone and betamethasone, drugs that can easily cross the placenta, are more suitable for fetal indications. During the last decade, administration of corticosteroids was introduced in the treatment of hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome), a severe form of preeclampsia unique to human pregnancy. Several randomized, controlled trials as well as other prospective and retrospective studies have been performed to investigate this beneficial effect of corticosteroids on biochemical measures and clinical signs. This review discusses the characteristics of corticosteroids in humans and details the use of corticosteroids during pregnancy. A review of literature on the effect of corticosteroids on HELLP syndrome is given and possible mechanisms of action are discussed.     

Drugs and the fetus

PURPOSE OF REVIEW: Few drugs are licensed in pregnancy, and data on drug use in pregnancy are mainly retrospective and uncontrolled. Pregnancy exposure has increased recently to new classes of drugs, as they have been shown to be effective and well tolerated outside of pregnancy. RECENT FINDINGS: Anti-nausea therapies, H2-receptor and proton pump inhibitors appear to be safe. Metformin is being trialed for treatment in gestational diabetes and initial reports appear encouraging. Concern has been raised about statins in early pregnancy and should be avoided. New antiepileptic medication appears effective with low risk of abnormality. However, when combined with valproate, risks are still high. Selective serotonin reuptake inhibitors for depression appear to be effective, with likely low risk for teratogenesis, although neonatal behavioural syndrome following their use in the third trimester is a concern. Angiotensin II inhibitors should be avoided in the second and third trimesters of pregnancy. Smoking cessation programmes need to be reevaluated. SUMMARY: Information about safety of drugs and caution about prescribing in pregnancy should continue. Until large clinical trials are performed, the risk/benefit ratio of drugs during pregnancy will remain uncertain.     

Primary empty sella syndrome with elevated serum prolactin

A young, adult, white female with long-standing amenorrhea-galactorrhea syndrome and known pituitary enlargement since 1969 is presented. Further evaluation revealed PRL levels elevated in the microadenoma range and an empty sella. The presence of a pituitary adenoma, however, could not be confirmed by our studies. The question now arises--in a young woman desirous of pregnancy, should an induction of ovulation be attempted in view of the elevated serum PRL and an empty sella?     

Primary amenorrhea-galactorrhea with hyperprolactinemia and huge pituitary enlargement in juvenile primary hypothyroidism.

We report a girl with juvenile primary hypothyroidism revealed by growth retardation and a syndrome of primary amenorrhea-galactorrhea with hyperprolactinemia and suprasellar pituitary enlargement. Resolution of the pituitary enlargement and the amenorrhea-galactorrhea syndrome occurred after thyroid hormone replacement. No similar observation has been reported earlier in juvenile hypothyroidism.     

Hyperprolactinemia with prolonged amenorrhea reversed with bromocriptine in a menopausal woman

Bromocriptine treatment of the amenorrhea-galactorrhea syndrome with elevated prolactin levels is well recognized. The return of menses after 30 years in a menopausal woman with this syndrome is described. Lowering of both prolactin and follicle-stimulating hormone levels was found to occur after bromocriptine therapy.     

Should we continue or stop insulin sensitizing drugs during pregnancy?

PURPOSE OF REVIEW: The use of insulin sensitizing drugs such as metformin in polycystic ovary syndrome has been increasingly popular and validated by systematic reviews. There has also been an interest in the use of metformin for gestational diabetes. However, administration of metformin to prevent miscarriage is controversial and widespread use of this drug in early pregnancy requires investigation. RECENT FINDINGS: There are claims that miscarriage and gestational diabetes are more common in polycystic ovary syndrome and that use of insulin sensitizers improves outcomes dramatically. This review suggests there is no evidence for increased risk of miscarriage solely due to polycystic ovary syndrome and that there are insufficient data for promoting therapy with metformin. There is some reason for use of metformin in mid-pregnancy for gestational diabetes but better evidence from randomized controlled trials is urgently needed. SUMMARY: The use of metformin in early pregnancy for reducing the risk of miscarriage should be avoided outside of the context of properly designed prospective randomized trials. Safety in early pregnancy appears to be reassuring but not completely proven. The use of metformin in mid-pregnancy for gestational diabetes appears more logical but also needs adequate trials before general use is advocated.     

Antecedent factors and outcome in amenorrhea-galactorrhea

One hundred seventeen patients with amenorrhea and galactorrhea or hyperprolactinemia were evaluated with regard to antecedent factors, results of investigations, and management. Full details of the outcome of prolonged follow-up were available for 104 patients. Patients who developed amenorrhea-galactorrhea after withdrawal of oral contraceptives or postpartum had a lower incidence of pituitary adenomas than did those who developed amenorrhea-galactorrhea spontaneously. Six of a total of 40 tumors were detected only during the follow-up period. This study suggests that patients with spontaneous amenorrhea-galactorrhea have a greater risk of developing a detectable pituitary adenoma than do those with postpill or postpartum symptoms. However, patients with a microadenoma are more likely to have had postpill onset of hyperprolactinemia. Plasma prolactin (PRL) in patients with postpill amenorrhea-galactorrhea increased in proportion to the duration of oral contraceptive use.     

Treatment of post-pill amenorrhea

Post-pill amenorrhea, a relatively rare but important sequela of oral contraceptive use, is often accompanied by galactorrhea. A review of women with post-pill amenorrhea-galactorrhea (PPAG) showed that it has more than one cause. Clinical and laboratory methods of evaluation are reviewed, and appropriate methods of treatment are suggested.     

Pharmacological treatment of severe hypertension in pregnancy and the role of serotonin(2)-receptor blockers

Hypertensive disorders of pregnancy are the leading cause of maternal and perinatal mortality and morbidity in developing and developed countries. The etiology of preeclampsia is still unknown. Delivering the baby is the only definite treatment. The benefits of acute pharmacological control of severe hypertension prior to and/or post-delivery are generally accepted. Most drugs commonly used in the management of severe hypertension in pregnancy have significant maternal and/or neonatal adverse side effects. Furthermore, some are not effective to acutely lower the blood pressure in patients with a hypertensive crisis. Until recently not one of the commonly used antihypertensive drugs has been tailored to the pathophysiology of severe preeclampsia, being a clinical syndrome characterized by endothelial cell dysfunction, vasospasm and platelet aggregation. Ketanserin, a serotonin(2)-receptor blocker, is a drug that appears to be tailored for treating this pregnancy-associated enthothelial cell dysfunction. The results of several prospective trials show that there is a definite place for serotonin(2)-receptor blockers in the treatment of pregnancy-induced hypertensive disorders. This review provides a summary on the more established drugs as well as on some of the newer antihypertensive drugs used in pregnancy with emphasis on the existing experience with ketanserin.     

Spontaneous pregnancy in women with a prolactin-producing pituitary adenoma

The occurrence of spontaneous pregnancy in patients with amenorrhea-galactorrhea, hyperprolactinemia, and radiographic evidence of a pituitary tumor is unusual. We present here two patients who conceived spontaneously. One had an uneventful pregnancy. Following delivery, transsphenoidal pituitary surgery was performed, confirming the presence of a prolactin-producing adenoma. The second patient had an early pregnancy termination (at 12 weeks of gestation). These patients provide evidence that ovulation and pregnancy can occur in spite of elevated prolactin levels.     

Use of herbal drugs during pregnancy among 600 Norwegian women in relation to concurrent use of conventional drugs and pregnancy outcome

Purpose

The purpose of this study was to investigate the use of herbal drugs by pregnant women in relation to concurrent use of conventional drugs, delivery, and pregnancy outcome.

Method

600 women at Stavanger University Hospital Norway were interviewed using a structured questionnaire within five days after delivery. Medical birth charts were reviewed with respect to pregnancy outcome.

Results

In all, 39.7% of the women reported having used herbal drugs during pregnancy, most commonly ginger, iron-rich herbs, echinacea and cranberry. Although 86.3% of the women reported having used conventional drugs during pregnancy there were few potential interactions between herbal drugs and conventional drugs. There was a significant association between the use of iron-rich herbs during pregnancy and high birthweight, and use of raspberry leaves and caesarean delivery.

Conclusion

Use of herbal drugs is common during pregnancy and indicates a need for documentation about their safety in pregnancy.     

Drug use during pregnancy: survey in 250 women consulting at a university hospital center

A prospective study of drug use in pregnancy was performed in the maternity outpatient department of a university hospital in Southwestern France. Two hundred and fifty pregnant women were selected at random and interviewed. Eighty-four percent of the women reported drug consumption, with an average of two medications per week. Some factors were significantly associated with an increase in drug use: European origin, high level of education, medical history, alcohol consumption. The most commonly used drugs were iron (43% of the women), medications for venous disorders (22%) and gynecology (21%) and analgesics (19%). Chronic use (beginning before pregnancy) occurred in 9% of the women. Self medication accounted for around 20% of the women. Adverse effects were described by the women 25 times out of 544 exposures: they concerned 10 drugs and were not "serious". After delivery, 14 cases of malformations of the new-born, three stillbirths, 25 neonatal pathologies and 10 resuscitations were observed. Except one neonatal withdrawal syndrome after "in utero" exposure to benzodiazepines, no relationship between drug exposure and pregnancy outcome could be established.     

Strategies for the use of insulin-sensitizing drugs to treat infertility in women with polycystic ovary syndrome

OBJECTIVE: Insulin resistance and its compensatory hyperinsulinemia play a key pathogenic role in the infertility of the polycystic ovary syndrome. Numerous studies indicate that insulin-sensitizing drugs can be used to enhance spontaneous ovulation and the induction of ovulation in the syndrome. The aim of this review is to summarize the studies in which insulin-sensitizing drugs were used to increase ovulation rate or improve fertility in women with the PCOS and to translate the information into practical guidelines for the use of these drugs by reproductive endocrinologists. DESIGN: Review and critique of studies in which an insulin-sensitizing drug was used to increase ovulation rate or improve infertility in women with the polycystic ovary syndrome. MAIN OUTCOME MEASURE(S): Ovulation rate and pregnancy rate. RESULT(S): Studies have demonstrated that insulin-sensitizing drugs can increase spontaneous ovulation, enhance the induction of ovulation with clomiphene citrate, and increase clinical pregnancy rates. CONCLUSION(S): An algorithmic approach is provided for the use of insulin-sensitizing drugs to treat the anovulation and infertility of women with the polycystic ovary syndrome.     

从《温病条辨》探析吴鞠通儿科用药特点

吴鞠通著《温病条辨》倡三焦辨证,形成了以卫气营血、三焦为核心的温病辨证体系,其中卷六《解儿难》结合温病理论阐释了其对儿科疾病和治疗用药的独特见解.吴鞠通解小儿"纯阳"为"稚阳未充,稚阴未长",其易于感邪、易于传变,治疗用药需谨慎.本文结合吴鞠通对小儿生理病理特点的认识,从谨慎选药、慎用苦寒、多甘少酸、巧用辛温、善用辛凉...     

Atopic dermatitis in pregnancy: current status and challenges

Atopic dermatitis (AD) is the most common pregnancy dermatosis. This evidence-based review article provides an evaluation of AD in gestation. Our literature search revealed 4 epidemiologic studies on AD in pregnancy, and a total of 55 articles that provide the basis for this review. The limitations of epidemiologic studies included herein are critically reviewed. The management of AD in gestation is reviewed with an emphasis on drug safety. Further studies are required to determine whether it is the intrinsic ("nonallergic" or "atopiform dermatitis") and/or extrinsic (IgE-associated) AD that is affected by pregnancy, and to establish the postpartum prognosis of "new atopic dermatitis" (AD presenting for the first time in pregnancy). A revision of the diagnostic criteria will allow a more accurate confirmation of the prevalence of AD, and especially "new atopic dermatitis," in pregnancy as well as differentiation of AD from specific dermatoses of pregnancy, such as prurigo and pruritic folliculitis. Addressing the above issues and unraveling the etiopathogenesis of AD in pregnancy will help clarify a suggested overlap with the above specific dermatoses.     

Etiology, clinical features and prognosis in secondary amenorrhea.

A clinical investigation of 356 patients with secondary amenorrhea revealed that 95% of patients with postpill amenorrhea and 56% of patients with anorexia nervosa recovered in 6 years. The corresponding recovery rates for patients with psychogenic amenorrhea and amenorrhea following self-induced weight loss were 72% for both groups, and in patients with the amenorrhea-galactorrhea syndrome and idiophatic functional amenorrhea the recovery rates at 6 years were 64 and 61% respectively. Unlike the other groups with functional amenorrhea, patients with the amenorrhea-galactorrhea syndrome had impaired ovarian responsiveness to exogenous gonadotropins. Bromocriptine treatment resulted in disappearance of the galactorrhea and restoration of the menses and/or ovulation in nine of 18 patients; of these three became pregnant. The effect of bromocriptine did not persist for long after treatment ceased, and permanent recovery was recorded only in four patients. The group with functional amenorrhea included 34 patients who wished to become pregnant. Gonadotropin treatment was successful in 20 patients, clomiphene-hCG in two, tamoxifen in two, bromocriptine in two, and combined bromocriptine and clomiphene in one. Thus, the overall pregnancy rate in patients with functional amenorrhea was 79%. The groups with ovarian amenorrhea inclutients with assumed ovarian failure responded to large doses of exogenous gonadotropins by ovulation and three became pregnant. Ovarian wedge resection was ineffective in all five cases with polycystic ovaries, but two patients became pregnant after treatment with clomiphene and chorionic gonadotropin, and one with exogenous gonadotropins.     

Drugs in pregnancy. Drugs to avoid.

Drugs given in pregnancy can adversely affect the fetus in many ways. Anxiety about birth defects is a major parental concern during pregnancy. Doctors, midwives and their patients often seek information about the potential teratogenicity of drugs that are taken by, or prescribed for, the pregnant woman. Because no drug is entirely without side-effects, great caution should be taken when prescribing in pregnancy. The development of knowledge in understanding the use of drugs during pregnancy has been in stalemate in comparison to other areas of therapeutics, due mainly to difficulties in testing new products in pregnant women and lack of good quality research. In this chapter, we review current knowledge of the epidemiology of drug use among pregnant women, drug metabolism in pregnancy, adverse fetal and neonatal effects of drugs and specific effects of drugs that are relatively or absolutely contraindicated in pregnancy.     

Drugs to avoid

Drugs given in pregnancy can adversely affect the fetus in many ways. Anxiety about birth defects is a major parental concern during pregnancy. Doctors, midwives and their patients often seek information about the potential teratogenicity of drugs that are taken by, or prescribed for, the pregnant woman. Because no drug is entirely without side-effects, great caution should be taken when prescribing in pregnancy. The development of knowledge in understanding the use of drugs during pregnancy has been in stalemate in comparison to other areas of therapeutics, due mainly to difficulties in testing new products in pregnant women and lack of good quality research.In this chapter, we review current knowledge of the epidemiology of drug use among pregnant women, drug metabolism in pregnancy, adverse fetal and neonatal effects of drugs and specific effects of drugs that are relatively or absolutely contraindicated in pregnancy.     

Drugs to avoid in pregnancy

Drugs given in pregnancy can adversely affect the fetus in many ways. Anxiety about birth defects is a major parental concern during pregnancy. Doctors and their patients often seek information about the potential teratogenicity of drugs that are taken by or prescribed for the pregnant woman. Because no drug is entirely without side effects, great caution should be taken when prescribing in pregnancy. The development of knowledge in understanding the use of drugs during pregnancy has been in stalemate in comparison to other areas of therapeutics, mainly due to difficulties in testing new products in pregnant women and paucity of good quality research. In this article, we aim to review current knowledge of the epidemiology of drug use among pregnant women, drug metabolism in pregnancy, adverse fetal and neonatal effects of drugs and specific effects of drugs that are relatively or absolutely contraindicated in pregnancy.