Natural Menopause Relief Secrets
Two alternatives to long-term estrogen therapy have been proposed, because of the fear of certain risks (particularly malignancy) that might result in postmenopausal women The dispute about the benefit to harm balance of the various competing forms of HRT for use in the climacteric or postmenopausally is becoming increasingly intense, with a sharp division of opinion between protagonists and critics of the individual patterns of treatment. The view was often defended by earlier workers that, at least for certain classes of users, some form of combined estrogen + progestogen treatment is likely to be more appropriate and perhaps more physiological than estrogen replacement alone. Many variants have been used and none is likely to be ideal for all subjects. Some have argued that in the climacteric there are sound reasons for using estrogen with intermittent progestogen and that it is much underused, despite the fact that uterine bleeding and other adverse progestogenic effects are, with...
The classic androgen is natural testosterone, which can be given orally in micronized form, but has much more often been used as the orally active 17-methyl derivative or an injectable ester. Androgens are used to some extent in male hypogonadism, when they can promote libido and potency and increase the frequency of erections and the volume of the ejaculate (1). The use of androgens by either sex as sexual tonics'' is a matter of dispute. Some centers have used androgens to treat postmenopausal women complaining of weak libido, poor energy, or a feeling of malaise (2) workers who use this contentious approach have suggested that they should be given in association with estrogens, because of the adverse effects of androgens on serum lipids. When androgen therapy is used in postmenopausal women who complain of poor libido, poor energy, or a feeling of malaise (2), it should be given in association with estrogens, because of its adverse effects on serum lipids.
Even the restrained scholarly prose of these sober scientists resonates with the staggering genetic implications of the turn-on role of nonhistone proteins. But when we consider the neurogenetic implications and the metamorphic suggestions these findings become even more important. We know that the DNA of the baby contains the coded instructions for manufacturing 14 years in the future ( ) a sexually equipped adult. Adolescence begins when the appropriate nonhistone proteins (NHP's) selectively turn on the generative (sperm-egg) section of the DNA code. Aging begins when the selective NHP turns on the menopausal section of the DNA. The DNA of the caterpillar contains the instructions for building a butterfly. The DNA of the four-brained Domesticated Ape (homo sapiens) contains the blueprint for the next mutational stages post-human, i.e., post hive.*
In 72 postmenopausal women (mean age 65 years) with established osteoporosis who took elemental calcium 1.0g day and vitamin D 400 U day, etidronate and hormones were compared (15). The Hormone Replacement Therapy (HRT) group (n 18) took cyclical estrogen and progesterone the etidronate group (n 17) took intermittent cyclical etidronate and the combined therapy group (n 19) took both HRT and etidronate. Three patients in the HRT group and two patients in the combined therapy group withdrew owing to estrogen-related adverse effects. One patient each from the control group and the etidronate group withdrew because of inability to tolerate the medications. Two patients each from the control and combined therapy groups, and one from the etidronate group withdrew owing to other medical problems. There was one death due to myocardial infarction in the etidronate group, and one patient in the control group was lost to follow-up. Six patients complained of nausea after etidronate, but...
Intermittent intravenous clodronate is effective in preventing and treating postmenopausal bone loss (42). In Italy, it is also available for intramuscular administration, which might be an acceptable alternative for some patients. However, intramuscular injection caused substantial pain at the site of injection, which led to withdrawal in almost 50 of the patients who received a weekly dose (43). These results suggest that intermittent intramuscular clodronate can improve skeletal bone density in osteoporotic postmenopausal women, but in situ pain may limit its extensive use.
If bromocriptine is to be used to treat infertility, the presence of a pituitary adenoma must be excluded, since this can otherwise undergo suprasellar extension during pregnancy. Because of its adverse reactions profile, bro-mocriptine is better avoided in patients with cardiac disease or peripheral vascular disease. Acromegaly in patients with a history of gastrointestinal ulceration or bleeding should not be treated with bromocriptine generally, however, it seems to be rather better tolerated by patients with acromegaly, as well as by postmenopausal women and patients with a raised serum prolactin concentration than by other patients.
In a randomized, placebo-controlled trial 22 of 1255 postmenopausal women taking calcitonin compared with 15 of women taking placebo had rhinitis (nasal congestion, discharge, or sneezing) (12). Almost all cases were of mild to moderate severity. In postmenopausal osteoporosis treatment with calcitriol plus etidronate or calcitonin produced improvement in spinal bone mineral density, but a high rate of nephro-toxic adverse events (14).
Loss of bone density in older women studies controlling other factors (such as cigarettes and drugs promoting calcium loss) found that caffeine had no tendency to reduce bone density, but one study published in 2000 and tracking almost 35,000 postmenopausal women found a slight correlation of caffeine usage to broken bones a correlation implying loss of density. Coffee drinking is associated with loss of density. In contrast, examination of over 1,200 older women in England showed that tea drinkers were less likely to have osteoporosis, leading investigators to wonder if something in tea, other than caffeine, affects bone density. Cancer. Caffeine does not seem to produce cancer in animal experiments. Indeed, green and black tea reduce development of cancer in mice, an effect in which caffeine is believed to play a part. In humans, however, caffeine is suspected of promoting premenopausal ovarian cancer and also cancer of the pancreas and bladder.
Women should be warned about the possibility of menstrual disorders after local triamcinolone injections (249). When premenopausal women received their first injection of triamcinolone intra-articularly (n 46), injected into soft tissue (n 24), or epidurally (n 7) they were specifically asked to report flushing or menstrual irregularities during a mean follow-up period of 6 weeks. Of the 77 women in the study, 39 reported menstrual disorders. The onset of menstruation was later than expected in ten women and earlier in 16 women. There was reduced loss of blood and or a shorter duration of menstruation in four women and increased loss of blood and or a longer duration of menstruation in 18. Also, 22 women had flushing. Menstrual disorders occurred significantly less often in women who were taking oral contraceptives.
It should be pointed out that not all erectile dysfunction is caused by serious health concerns. It can also come with the normal decline in testosterone in men as they age, the so-called male menopause. Unfortunately, not a lot is really known about male menopause. For a long time, it wasn't even recognized as a part of normal aging. It had, however, been known for some time that testosterone levels fall with age. Besides keeping people sexually active, which can have very positive effects on mental health, the Viagra craze has made it OK for men to talk about a problem that before would have devastating psychological effects and is commonly hidden from doctors and significant others. It also brings up the hypocrisy of a nation that feels comfortable with television ads for erectile dysfunction drugs during prime time television, but has a problem with a television show that discusses sex or an ad for contraception during the same time slot. Since there are no approved pharmaceutical...
The effects of estrogens on mood tend to be positive, and improved performance in intellectual tests has been described (SEDA-20, 382) (22) this is in parallel with the known effects of endogenous estrogens. During the menopause some women become depressed and irritable, and the ability of estrogens to correct this has been delineated in various studies, including work with estradiol given transdermally (23). Some workers also claim increased vigilance, and have concluded that this is reflected in encephalographic changes. There is even some evidence of an improvement in mental balance and self-control when estrogens are given to demented and aggressive old people of both sexes (24). However, all of these effects of estrogens on mood or mental performance are only likely to last for as long as the treatment does, and the effects on mood may occur only at the start of treatment altered mood can follow acute withdrawal.
A subfertile man treated with human menopausal gona-dotropin + human chorionic gonadotropin (hMG + hCG) developed a malignant teratoma of the testis however, in view of his history a cause-and-effect relation was dubious (28). The numbers of women who had used clomiphene or human menopausal gonadotropin were too small to make more differentiated calculations, but the incidence of melanoma seemed to correspond to that in the general population. alternating with repair involving mitogenic activity and thereby in turn a risk of mutations (42). On the other hand, as has been pointed out, no correlation has been found between the risk of ovarian cancer and the age at menarche and menopause, that is the length of the fertile period, which might be anticipated if the so-called ovulation hypothesis is correct.
Tamoxifen is used in postmenopausal women with estrogen-receptor-positive tumors, patients with long disease-free intervals following treatment for early breast cancer, and those with disease limited to bone or soft tissues. However, aromatase inhibitors, such as letrozole or anastrozole, may be more efficacious and are regarded as the preferred treatment in postmenopausal women. Ovarian ablation or a gonadorelin analog should be considered in premenopausal women. Progestogens such as medrox-yprogesterone acetate continue to be used in advanced breast cancer in postmeno-pausal women. They are as effective as tamoxifen but are not as well tolerated. However, they are less effective than the aromatase inhibitors. Cytotoxic chemotherapy is preferred for advanced estrogen-receptor-negative tumors and for aggressive disease, particularly where metastases involve visceral sites (e.g., the liver) or where the disease-free interval following treatment for early breast cancer is short.
The theoretical starting point is the observation that (particularly after oophorectomy) there are deficiencies of both testosterone and androstenedione (3) and from the observation that estrogens alone do not relieve all menopausal symptoms. While there may well be justification for androgen replacement after oophorectomy, it is not clear that most of the claims made for use of this approach following a natural menopause are sufficiently well founded to justify the risks involved. Adding an androgen to estrogen replacement therapy in the menopause has been thought to provide supplementary benefit with respect to climacteric symptoms, fatigue, and impaired libido, as well as favorably affecting muscle mass, skin quality, and bone density. It is also stated that androgens improve relief of vasomotor symptoms and relieve depression and anxiety when they occur after the menopause in this group of patients. Some workers have concluded that in women who respond to conjugated estrogens with...
Another variant on hormone replacement therapy involves using all three types of sex steroid in parallel, starting from the argument that during the fertile period all three are synthesized by the ovary (7). A natural version of this therapy uses estradiol, testosterone (with or without dehydroepiandrosterone), and progesterone in an appropriate pharmaceutical form (for example micro-nized), so that absorption is attained without the need for 17-substitution. This approach naturally avoids some of the undesirable effects of the synthetic steroids, and has been stated to improve menopausal depression and anxiety. However, the adverse effects of all three types of component can be experienced.
A Japanese study of the use of estriol 2 mg day for 12 months in 68 postmenopausal women with climacteric symptoms showed a significant effect in relieving hot flushes, night sweats, and insomnia (8,9). There were significant falls in serum follicle stimulating hormone (FSH) and luteinizing hormone (LH) concentrations, but no effect on lipids, bone demineralization, or blood pressure. There was slight vaginal bleeding in 14 of women treated during a natural menopause, but histological and ultrasound evaluation showed no changes in the endometrium or breasts. It is evident, however, that higher doses might be needed when treating women of other races with a higher body weight. Other workers have found that when given with a progestogen over long periods, estriol 2.0 mg day seems much less likely to cause undesirable lipid changes than are equine conjugated estrogens, which can cause increased HDL cholesterol and triglyceride concentrations (10).
When a young woman undergoes a surgical menopause it is clear that estrogen replacement treatment, if given at all, is likely to be needed for many years, and in the present state of knowledge this is probably justifiable, provided that the effects are monitored. The dilemma that the physician faces in such cases has been discussed in the light of a patient in whom gross obesity compounded the possible risk of thrombosis the patient was
It is widely recommended that estrogen replacement therapy, if it is to be used at all, should be initiated at the time of menopause or within 3 years of it, since it is at this time that bone loss can be most severe. Many physicians go on to argue that once it has been started hormonal replacement therapy should continue for at least 20 years and perhaps indefinitely, in view of evidence that withdrawal may be followed by accelerated bone loss, at least comparable to that observed after the menopause. Later use of estrogen, once bone has already been lost, does not result in appreciable recovery of bone, although further loss can still be prevented. Large comparative studies have suggested that a series of alternative regimens for hormone replacement therapy should be available, so that for each individual woman the most appropriate form of treatment can be chosen no one regimen is ideal for all, and finding the best approach for a given patient may be a matter of trial and error...
In a case-control study 155 postmenopausal women who had had venous thromboembolism were compared with 381 matched controls (45). In all, 32 cases and 27 controls were current users of oral replacement therapy, whereas 30 cases and 93 controls were current users of transdermal products. After adjustment for potential confounding variables, the estimated risk ratio for venous thromboembolism in current users of the oral products compared with the transdermal users was 4.0 (1.9-8.3). This is strong evidence that the transdermal route was considerably safer. However, the conclusions of different studies continue to conflict with one another, no doubt in part because of variations in the formulations and patterns of use of the products.
Of 206 postmenopausal women who took the oral combination of estradiol valerate plus norethisterone (5) eight withdrew because of bleeding during year 1 during years 2 and 3 there were no withdrawals because of bleeding. By the end of year 3, 133 patients had completed the study. There were serious adverse effects in 24, but there was no definite relation to therapy. The numbers of adverse events reported each year by the patients who completed the study are shown in Table 1. The authors concluded that this combination was effective in the majority of patients and was well tolerated.
When patients have adverse effects during combined hormone replacement therapy it is necessary to determine whether the progestogen or the estrogen is causing the problem. If heavy bleeding or breast tenderness is the primary complaint, the estrogen component is probably the problem and therefore the dose should be reduced. If the patient complains of irritability, depression, water retention, or headaches, the problems are probably due to the progestogen component and the latter should in that case be changed or the dose adjusted since several different progestogens are in use (particularly norethindrone, norethindrone acetate, medroxyprogesterone acetate, and micronized progesterone) there is a degree of choice.
With increasing concern over the long-term safety of hormone replacement therapy, the benefit to harm balance has Menopausal symptoms to be continually reassessed, and conclusions as to its prophylactic or therapeutic value need to be adjusted as experience accumulates. Not all the promises held out for the benefits of this therapy have been confirmed. For example, while estrogens prevent peripheral bone loss they do not prevent vertebral fractures (6) and in a 2-year placebo-controlled, crossover study in 34 healthy postmenopausal women, treatment with transdermal estrogen alone (Menorest 50 micrograms day) did not improve lipid profiles or any indices of arterial function (7). It is remarkable that, despite decades of accumulated observational evidence, the balance of benefits and harms for hormone use in healthy postmenopausal women remains uncertain (8). Quite apart from the constantly changing spectrum of the available data, one explanation for the confusion is the relatively...
The impact of a new formulation of low-dose micronized medroxyprogesterone plus 17-beta-estradiol on lipid profiles in menopausal women has been studied for 12 months. Total cholesterol concentrations fell 8.4 , low-density lipoprotein cholesterol fell 18 , and high-density lipoprotein cholesterol increased 6.9 total triglycerides increased 12 . The most frequently reported adverse events were menorrhagia, breast tenderness, cervical polyps or cysts, bloating, fatigue or lethargy,
In 438 postmenopausal women, randomly assigned to either constant 17-beta-estradiol (1 mg day) plus inter mit-tent norgestimate 90 micrograms (3 days off, 3 days on) or a fixed combination of 17-beta-estradiol (2 mg day) with norethisterone acetate (1 mg), the two regimens had similar bleeding profiles and provided comparable relief from vasomotor symptoms (1). However, breast discomfort and edema were experienced by twice as many subjects who used the fixed combination. The intermittent regimen was notably free of endometrial hyperplasia.
Menotropins (Pergonal) and urofollitropin (Metrodin) are purified preparations of the gonadotropins (FSH and LH) extracted from the urine of postmenopausal women. Menotropins are used to induce ovulation and pregnancy in anovulatory (failure to produce an ovum or failure to ovulate) women. Menotropins are also used with human chorionic gonadotropin in women to stimulate multiple follicles for in vitro fertilization. In men, menotropins are used to induce the production of sperm (spermatogenesis). Urofollitropin is used to induce ovulation in women with polycystic ovarian disease and to stimulate multiple follicular development in ovulatory women for in vitro fertilization. See the Summary Drug Table Anterior and Posterior Pituitary Hormones for additional information on the gonadotropins.
Oral contraceptives are divided into two types progestogen only and combined estrogen and progestogen. Most oral contraceptives are substrates for CYP3A4 (49). 17-Ethynylestradiol is a major component of oral contraceptive pill and is also used in hormonal replacement therapy in postmenopausal women. It is metabolized through hydroxylation in position 2 by CYP3A4 (50). St. John's wort has significant interaction with oral contraceptives (51). Muprhy et al. studied interaction between St. John's wort and oral contraceptives by investigating phramacokinetics of norethindrone and ethinyl estradiol using 16 healthy women. Treatment with St. John's wort (300mg three times a day for 28 days) resulted in a 13-15 reduction in dose exposure from oral contraceptives. Breakthrough bleeding increased in treatment cycle as did evidence of follicle growth and probable ovulation. Authors concluded that St. John's wort increased metabolism of norethindrone and ethinyl estradiol and thus interfered...
The full effects of thyroid hormone replacement therapy may not be apparent for several weeks or more, but early effects may be apparent in as little as 48 hours. During the ongoing assessment, the nurse monitors the vital signs daily or as ordered and observes the patient for signs of hyperthyroidism, which is a sign of excessive drug dosage. Signs of a therapeutic response include weight loss, mild diuresis, a sense of well-being, increased appetite, an increased pulse rate, an increase in mental activity, and decreased puffiness of the face, hands, and feet.
Older adults are more sensitive to thyroid hormone replacement therapy and are more likely to experience adverse reactions when taking the thyroid hormones. In addition, the elderly are at increased risk for adverse cardiovascular reactions when taking thyroid drugs. The initial dosage is smaller for an older adult, and increases, if necessary, are made in smaller increments during a period of about 8 weeks. Periodic thyroid function tests are necessary to monitor drug therapy. Dosage may need to be reduced with age. If the pulse rate is 100 bpm or more, the nurse notifies the primary health care provider before the drug is administered.
Thyroid hormones are usually given on an outpatient basis. The nurse emphasizes the importance of taking the drug exactly as directed and not stopping the drug even though symptoms have improved. The nurse provides the following information to the patient and family when thyroid hormone replacement therapy is prescribed
Before the 20th century this temporal caste occurred in individuals when the 12th brain, the Neurotechnology of Dying, was activated. Usually at menopause. The young of the species, however, could still get involved in tribal (Stage 9), national (10) and political (11) conflicts or engage in western migrations, scientific progress, socialist-Utopian yearnings. During the 20th century the Dom Species became Caste 12. The entire human race began to sense that the terrestrial game is over. Exploration of frontiers finished. Over-population, pollution, diminished resources, Hiroshima-Nagasaki, agonizing discrepancies between the affluent-scientific west and the impoverished-religious east Doomsday-Armageddon scenarios proliferate And here come the religious dogmas
Before administering an estrogen or progestin, the nurse obtains a complete patient health history, including a menstrual history, which includes the menarche (age of onset of first menstruation), menstrual pattern, and any changes in the menstrual pattern (including a menopause history when applicable). In patients prescribed an estrogen (including oral contraceptives), the nurse obtains a history of thrombophlebitis or other vascular disorders, a smoking history, and a history of liver diseases. Blood pressure, pulse, and respiratory rate are taken and recorded. The primary health care provider usually performs a breast and pelvic examination and obtains a Pap smear before starting therapy. He or she may also order hepatic function tests.
A wealth of epidemiological, clinical, and experimental studies link estrogens with cardiovascular disease (CVD). This evidence has promoted CVD as a key area within the extragenital effects of estrogens. The question is of interest because it directly affects the wide clinical use of estrogens as contraceptive agents or as principal constituents of hormonal therapy (HT) formulations in postmenopausal women. The significance of the subject is further reinforced by the relevance of CVD as a cause of mortality and morbidity in both women and men. mation gathered in the latter years has confirmed the association of estrogens with many benefits both in experimental as well as in clinical models at the level of intermediate indicators. Consequently, HT was proposed not only for control of symptoms but also for primary and secondary CHD prevention in postmenopausal women. Contrary to the beneficial effects found in the first, observational studies, three more recent randomized controlled...
Even in cases where there is failure to find group differences, there are often correlations within the PTSD group with indices of PTSD symptom severity. Baker et al. (1999) failed to find group differences between Vietnam veterans with PTSD compared to non-exposed controls, but did report a negative correlation between 24-h urinary cortisol and PTSD symptoms in combat veterans. A negative correlation between baseline plasma cortisol levels and PTSD symptoms, particularly avoidance and hyperarousal symptoms, were observed in adolescents with PTSD (Goenjian et al. 2003). Rasmusson et al. (2003) failed to observe a significant difference in urinary cortisol between premenopausal women with PTSD and healthy women, but noted an inverse correlation between duration since the trauma and cortisol levels, implying that low cortisol is associated with early traumatization. This finding is consisted with Yehuda and colleagues' observation of an inverse relationship between childhood emotional...
Angelicae Radix has been used as a sedative or a tonic and to treat disorders of menstruation in women, anemia, and menopause syndrome. Angelica gigas Nakai (Um-bellaceae) is used in Korea, and A. sinensis (Oliv.) Diels is used in China. A. gigas includes decursin, decursinol angelate, angelan, and decursinol. A. gigas protects mice against AP-induced memory impairment 107 . A. gigas has antinociceptive effects on pain responses induced by TNF-a, IFN-y, IL-1P, glutamate, NMDA, or kainic acid 108 . Decursin ameliorates scopolamine-induced memory impairment in mice 109 . Decursinol and decursin protect primary cultured rat cortical cells against glutamate-induced oxidative stress by both reducing calcium influx and acting on the cellular antioxidative defence system 110 .
Methyltestosterone is a synthetic drug manufactured from testosterone. Methyltestosterone's medical uses include supplementation of testosterone in males with low levels of that hormone and treatment of female breast cancer. Scientists report unsatisfactory results from a test of whether the compound might work as a male contraceptive and mixed results when the substance was used to treat male impotence. Impotence improvement was better when methyltestosterone was taken in combination with a yohimbe preparation. Methyltestosterone has provided pain relief and occasionally fertility enhancement to women suffering from a reproductive disorder called endo-metriosis externa. Therapeutic regimens to build up bone strength in older women may include methyltestosterone, as may therapies designed to compensate for hormonal changes caused by menopause. In research projects height increase occurred when the drug was administered to boys of short stature. Experimenters describe the drug as...
Pharmaceutical interest A common example of Verbenaceae is Lantana camara (yellow sage, common Lantana), the fruits of which have been responsible for children poisoning. The toxic principles are pentacyclic triterpene derivatives, lantadene A and B which provoke cholestasis, hepatic necrosis, gastroenteritis with bloody, watery feces, weakness, paralysis of the limbs and death in three to four days. Another example is Tectona grandis L. f., commercially known as teak wood. The dried leaves of Aloysia triphylla (LHerit.) Britt. (Lippia citriodorata H.B. and K.) or lemon verbena is used to treat digestive and nervous ailments. Verbena officinalis L. (French Pharmacopoeia) is traditionally used to promote urination and to soothe inflamed skin. This was known at the time of the Roman emperor Theodosius (4th century AD) to remove tumors. Vitex agnus-castus L. (chaste tree) has been used medicinally since the Greek time, and is still used to treat premenstrual syndrome and menopause....
Efforts continue to define the usefulness and unwanted effects of tibolone, with its unusual mixed spectrum of estrogenic, progestogenic, and androgenic effects. There is a widespread view that it could be preferable to other compounds in countering osteoporosis in post-menopausal women, particularly regarding adverse effects (114r). In an Italian study of 200 women taking different forms of HRT, estradiol with medroxyprogesterone acetate was compared with continuous tibolone 2.5 mg day (115Cr). Mastodynia sufficient to require withdrawal was less common with tibolone (4 vs. 13 ), as was irregular bleeding (19 vs 42 ), but there was modest weight gain 23 of users reported a gain of at least 2 kg because of which half of them suspended treatment. Only half of the original women were still taking treatment in each group 2 years after the start of therapy. 14. Lonning PE, Taylor PD, Anker G, Iddon J, Wie L, Jorgensen L-M, Mella O, Howell A. High-dose estrogen treatment in postmenopausal...
To assess the potential for an interaction between ralox-ifene and warfarin, 15 healthy postmenopausal women each received single doses of warfarin 20 mg before and during 2 weeks of dosing with raloxifene 120 mg day (20). Raloxifene reduced the oral clearance of R- and S-warfarin respectively by 7.1 and 14 and the oral volume of distribution by 7.4 and 9.8 . Raloxifene reduced the maximum prothrombin time by 10 and the area under the prothrombin versus time curve from 0-120 hours by an average of 8 . The authors concluded that raloxifene may produce a small increase in systemic warfarin exposure but a reduced pharmacodynamic effect. Since the effects are slight this interaction is unlikely to have clinical consequences.
Black cohosh, a herb reported to be beneficial in managing symptoms of menopause, is generally regarded as safe when used as directed. Black cohosh is a member of the buttercup flower family. The dosage of standardized extract is 2 tablets twice a day, or 40 drops of standardized tincture twice a day or one 500- to 600-mg tablet or capsule three times daily. Black cohosh tea is not considered as effective as other forms. Boiling of the root releases only a portion of the therapeutic constituents. Reduction in physical symptoms of menopause hot flushes, night sweats, headaches, heart palpitations, dizziness, vaginal atrophy, and tinnitus (ringing in the ears) Decrease in psychological symptoms of menopause insomnia, nervousness, irritability, and depression
At the time of each office or clinic visit, the nurse obtains the blood pressure, pulse, respiratory rate, and weight. The nurse questions the patient regarding any adverse drug effects, as well as the result of drug therapy. For example, if the patient is receiving an estrogen for the symptoms of menopause, the nurse asks her to compare her original symptoms with the symptoms she is currently experiencing, if any. The nurse weighs the patient and reports a steady weight gain or loss. A periodic (usually annual) physical examination is performed by the primary health care provider and may include a pelvic examination, breast examination, Pap smear, and laboratory tests. The patient with a prostatic or breast carcinoma usually requires more frequent evaluations of response to drug therapy.
The source of a drug does not determine whether a drug is safe or whether its use makes sense. Just because a drug is derived from nature doesn't make it safe. Many poisons are made by Mother Nature. Curare, a muscle paralyzer used by native South Americans for hundreds of years to kill animals, is derived from plants. Opium, morphine, and heroin are synthesized from the poppy plant. Alcohol is synthesized from grapes or grain. Marijuana leaves are smoked without any preparation at all besides drying. Hormones for menopause or birth control can cause strokes, blood clots, and mood swings. Tryptophan, a naturally occurring amino acid promoted as a sleep aid causes a potentially fatal disorder called eosinophilia-myalgia syndrome in some people who take it.
A 3-year, open study (5) has been performed with monofluorophosphate in 60 patients under 75 years old (average age 62 years, body weight 42-84 kg, height 148-174 cm) with established postmenopausal vertebral osteoporosis and a lumbar t-score lower than -2.5 BDM (measured by dual-energy X-ray absorptiometry) and at least one vertebral fracture diagnosed according to WHO criteria (6). The patients had taken hormone replacement therapy for an average of 2 years. Patients with inflammatory rheumatic diseases and those who were taking other medications that can modify bone metabolism, such as calcitonins, bisphospho-nates, vitamin D, or anabolic agents, were excluded. There were adverse events in 19 patients, 10 of which were probably due to the monofluorophosphate or calcium components, three with gastrointestinal symptoms and seven with leg pain. The other nine adverse events were probably due to the hormone replacement therapy component three with vaginal bleeding, four with
Ortopsique Diazepam. Ortrin Drug containing more than one substance whereof one under international control Pentobarbital sodium. Ortedrine Amfetamine. Ortenal Drug containing more than one substance under international control Amfetamine sulfate and Phenobarbital. Orzolon Methaqualone hydrochloride. Osley Colloquial term for LSD. Osmond, Humphrey American psychiatrist and one of the most enthusiastic proponent for the use of LSD in psychiatric treatment in the 1950s. He also coined the word psychedelic. Osomiate Artemisia mexicana. Ospalivina Morphine. Ossazepam Oxazepam. Ossicodone Oxycodone. Ossidndrocodeinona Oxycodone. Ossimorfone Oxymorphone. Osteoporosis Disorder in which the normal replenishment of old bone tissue is disrupted, as it usually is throughout life, resulting in weakened bones and increased risk of fracture. It is most common in women after menopause, although it can also occur in younger women and men. It is aggravated by a variety of...
Hormone replacement therapy (HRT) (SED-14, 1457 SEDA-23, 440 SEDA-24, 468 SEDA-25, 479) The dispute about the benefit harm ratio of the various competing forms of HRT for use in the climacteric or postmenopausally is becoming increasingly intense, with a sharp division of opinion between protagonists and critics of the individual patterns of treatment. The view was often defended by earlier workers that, at least for certain classes of users, some form of combined estrogen plus progestogen treatment is likely to be more appropriate and perhaps more physiological than replacement with estrogen alone. Many variants have been used and none is likely to be ideal for all subjects. Rosenberg is one of those who argue that in the climacteric there are sound reasons for using estrogen with intermittent progestogen and that it is much underused, despite the fact that uterine bleeding and other adverse progestogenic effects are with some combined formulations (but not all) major reasons for...
Is responsible for maintaining the corpus luteuni of pregnancy. FSH and a mixture of FSH and LH have been used therapeutically. Human menopause gonadotrophins (hMG) and hCG are two of these mixtures analogs arc menotropin and urogonadotropin). These hormones are used for ovulation induction and for additional support of the corpus luteum. Inducing ovulation with gonadotrophins can lead to multiple pregnancies of these, 5-6 involve triplets (Scialli 1986). Two publications report on a rare complex of multiple malformations and four cases of neuroblastoma in infants below 1 year, born of pregnancies involving exposure to gonadotrophins (Mandel 1994, Litwin 1991). These findings were not confirmed in other studies, nor were other pregnancy risks or abnormalities in early childhood and pubertal development associated with use of these agents for ovulation induction.
Intermittent dosing is usually as effective as continuous administration. Beneficial effects are seen within one to two days and response rates for improvements in mood and physical symptoms are about 50 to 60 . Evidence of long-term efficacy is lacking. Specialists recommend continuing treatment until the menopause as there is evidence that stopping treatment precipitates recurrence. Nevertheless, a trial period off treatment may be worthwhile after two years if supported by the patient.
Alcoholic liver disease may also produce femi-nization in men, as a result of impaired metabolism (breakdown) of female sex hormones such as estrogen. Signs of such feminization in men include gynecomastia (enlarged breasts) and female fat distribution. In women who drink alcohol excessively, there is a high prevalence of gynecologic disorders (missed periods and problems in functioning of ovaries) and a possibly earlier onset of menopause than in nondrinkers. In women alcohol is metabolized at different rates according to the particular phase of the menstrual cycle. Other hormonal effects have been described in association with acute alcohol ingestion, including the impaired release of growth hormone and increased release of prolactin, a hormone involved in milk production. Thyroid function, which controls the body's rate of metabolism, can be indirectly affected as a result of alcoholic liver disease. This effect occurs from impaired conversion of T4 (a form of thyroid hormone) to...
It was previously mentioned that in postmenopausal women, who show the highest incidence of breast cancer, estrogens are produced in adipose tissues and in the breast by the action of aromatase on androstenedione. However, the clinical response to aromatase inhibitors is not as high as expected, and often it is not superior to the one obtained with antiestrogens or with other antihormones. Furthermore, there appears to be no relationship between the clinical response and the degree of suppression of circulating estradiol levels, which suggests that other factors besides the classical estrogens must be involved in tumor growth.33 Steroids with estrogenic properties can be biosynthesized by a route involving the steroid sulfatase (STS) enzyme, which regulates the formation of estrone by hydrolysis of estrone sulfate (E1S) and also controls the hydrolysis of dehydroepian-drosterone sulfate (DHEA-S) to dehydroepiandrosterone (DHEA). The latter compound can be reduced to 5-androstene-3p,...
Postoperative radiation therapy also plays an important role in selected patients treated with mastectomy. The Danish Breast Cancer Cooperative Group (DBCCG) 82b trial randomized 1708 pre-menopausal women with either stage-II or stage-III breast cancer treated with mastectomy and chemotherapy with cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) to postoperative radiation vs no further therapy (Overgaard et al. 1997). This study found that the patients randomized to the postmastectomy radiation therapy arm had significantly improved 10-year locoegional control rate (91 vs 68 p
To synthesize a calcium transport protein. The final l,25(OH)2D3 product can be considered a kidney hormone that regulates calcium intake. Finally, l,25(OH)2D3 is oxidized to inactive calcitroic acid that is excreted through the kidney. The 24,24(OH)2D3 metabolite may be part of the degradation process for 25(OH)D3 that is not transported to the kidney, but it also can elevate serum calcium levels (16). Patients with kidney failure can experience vitamin D-resistant rickets. Because they cannot carry out the final hydroxylation step, l,25(OH)2D3 (calcitriol) is prescribed for their hormone replacement therapy.
The first discovered antiestrogen was clomiphene, but its development for the treatment for advanced breast cancer was discontinued because of concerns about potential side effects. In 1974, tamoxifen was the first antiestrogen to be approved for the treatment of advanced breast cancer (Great Britain) and in 1977 a similar approval was given by the FDA. Since then, tamoxifen has become the standard therapy for all types of ER-positive breast cancer. In the 1990s, it was also the first cancer chemopreventive agent approved by the FDA for the reduction of breast cancer in pre- and postmenopausal women with high risk.5 Tamoxifen also binds with high affinity to other targets, such as the microsomal antiestrogen group linking the phenyl ring that contains the basic side chain. The main representative of this family is raloxifene, which was identified as an antiestrogen but it was approved by the FDA only for the prevention of osteoporosis, while studies as a treatment for breast cancer...
The SERMs, especially tamoxifen and toremifene, have been the preferred first-line hormonal therapy in estrogen-responsive postmenopausal breast cancer, but they have several disadvantages that are related to their partial estrogenic agonistic activity. These include tumor stimulation in some patients at the initial stages of the treatment (tumor flare) and increased hot flashes, endometrial cancer, and thromboembolism. These limitations stimulated the search for pure ER antagonists. which has been approved for the treatment of postmenopausal women with hormone-sensitive advanced breast cancer following prior endocrine therapy.15 premenopausal women and in a postmenopausal group where both tamoxifen and aromatase inhibitors have failed.
Several atypical retinoids have also been assayed for cancer chemoprevention. Fenretinide, an amide of tretinoin that acts as a ligand of RAR-p and RAR-g receptors, has entered clinical trials showing a beneficial effect in the prevention of premenopausal breast cancer in combination with tamoxifen.57 Polyprenoic acid, also called acyclic retinoid, has shown RAR, RXR, and PPAR activities and is useful in the prevention of hepatocellular carcinoma.58 Finally, adapalene prevents cancer in patients with cervical intraepithelial neoplasia.
Male hormone replacement therapy has been reviewed (11). Hypogonadism can be accompanied by hot flushes, similar to those seen in postmenopausal women, and gyne-comastia. The potential risks of testosterone replacement in adult men are precipitation or worsening of sleep apnea, hastened onset of clinical significant prostate disease, benign prostatic hyperplasia, prostatic carcinoma, gynecomastia, fluid retention, polycythemia, exacerbation of hypertension, edema, and an increased risk of cardiovascular disease. There are clear differences of opinion about the use of androgens in women. An Australian reviewer has argued that women may have symptoms secondary to androgen deficiency and that prudent'' androgen replacement can be effective in relieving both the physical and psychological symptoms of such insufficiency (13). The reviewer suggested that testosterone replacement for women is safe, with the caveat that doses should be restricted to the therapeutic window for androgen...
The proliferative effects of tamoxifen on the endometrium have been supported by molecular data. The expression of both ER and progesterone receptors (PRs) was found to be consistently positive in endometria from women treated with tamoxifen for 1 month (Cano et al. 2000). That positivity has been reported to be even higher than that found in a control group of pre-menopausal women (Kommoss et al. 1998). Tamoxifen also mimicked estradiol treatment in up-regulating ERs, c-fos, and glyceraldehyde phosphate dehydrogenase mRNAs, together with other estrogen-induced genes (Rivera-Gonzalez et al. 1998 Robertson et al. 1998). The bromo-deoxyuridine index, an indicator of cell mitogenesis, has been shown to increase in endome-trial cells from tamoxifen-treated uteri (Karlsson et al. 1998 Carthew et al. 1999). In this connection, the expression of markers of proliferation, e.g., Ki67, was potentiated by tamoxifen in human endometrium (Elkas et al. 1998). More recently, tamoxifen increased Ki67...
Estradiol (E2), the principal estrogen, is synthesized in the ovaries from androstenedione by aromatase. However, in postmenopausal women for whom ovarian synthesis has ceased, local synthesis occurs in adipose and other tissues, especially the breast, where E2 levels are 20-fold higher than in plasma. After entering the cell, E2 binds to the estrogen receptor, which leads to a conformational Some other hormonal agents are also used in the treatment of breast cancer. For example, trilostane is licensed for postmenopausal breast cancer. It is well tolerated but diarrhea and abdominal discomfort can be a problem. Trilostane causes adrenal hypofunction, and so corticosteroid replacement therapy is required. Also, the use of bisphosphonates in patients with metastatic breast cancer may prevent skeletal complications of bone metastases.
For women of childbearing age, therefore, gout therapy is only a minimal issue. Gout is caused by an elevated level of uric acid in the blood and in the tissue. Uric acid is the end product of purine metabolism. Interval treatment between gout attacks with uricosurics and allopurinol aims to lower uric acid levels.
Israel E, Banerjee TR, Garrett MPH, Fitzmaurice GM, Kotlov TV, LaHive K, LeBoff MS. Effects of inhaled glucocorticoids on bone density in pre-menopausal women. New Engl J Med 2001 345 941-7. A. Inhaled corticosteroids reduce bone mineral density in early postmenopausal but not premenopausal asthmatic women. J Bone Miner Res 2001 16 782-7.
The aromatase inhibitor letrozole is prescribed to postmenopausal women with hormone-dependent breast carcinoma. Recently, letrozole has also found application in the treatment of sterility, in order to stimulate ovulation - for example, as alternative to clomiphene. A recently published retrospective study on 911 newborns from women who conceived following clomiphene ( 397) or letrozole (n - 514) treatment found no difference in the overall rates of major and minor congenital anomalies (Tulandi 2006),
Among the androgens available in drug form are mesterolone, testolactone, and testosterone. There is no indication for using this class of drugs during pregnancy. All of the earlier common reasons (i.e. psychosexual) for giving androgens to premenopausal women are considered outdated. Use of androgens to inhibit lactation also reflects outmoded practice.
The first step in managing a breakthrough episode of either mania or depression is to check medication adherence, evaluate other potential precipitants of relapse (e.g., seasonal changes, which are common in bipolar disorder, onset of peri-menopause, severe stressors, recurrent substance abuse, etc.) and evaluate medication doses and blood levels. Patients on lithium should have thyroid function tests checked as
Aromatase catalyzes the loss of the C-19 methyl group as a formic acid molecule, allowing the creation of the aromatic A ring that is characteristic of estrogens (Fig. 3.14). Aromatase inhibitors are employed for the therapy of breast cancer in postmenopausal women, for whom the primary estrogen source is aromatase activity in adipose tissues in the breast, bone, vascular endothelium, and central nervous system and aromatase levels are not under gonadotropin regulation. In premeno-pausal women, the use of aromatase inhibitors leads to incomplete estrogen suppression and increased gonadal stimulation due to the feedback regulatory mechanism that increases luteinizing hormone and follicle-stimulating hormone after aromatase inhibition (see also Section 3.9). This complication is not observed in postmenopausal women.
The gonadotropins LH and FSH in the female, when released from the anterior pituitary gland, act on the ovaries to stimulate the synthesis and release of the sex steroids estrogen and progesterone, and maintain folliculogenesis. The gonadal steroids complete the feedback loop by exerting a primarily negative feedback action on the hypothalamus and pituitary gland, to inhibit GnRH and LH FSH secretion, respectively. Humans and monkeys exhibit an average 28-day menstrual cycle characterized by a follicular phase, during which ovarian follicles develop and recruitment of the preovulatory follicle occurs, the preovulatory phase, where there is maturation and ovulation of the dominant follicle, and the luteal phase, which is dominated by the progesterone-secreting corpus luteum. The effects of THC exposure during the different phases of the menstrual cycle have been studied in both humans and monkeys. When a marijuana cigarette was smoked by women during the luteal phase, there was a 30...
All women with early breast cancer should be considered for adjuvant therapy following surgical removal of the tumor because adjuvant therapy can help eradicate the micrometastases that cause relapse. The choice of adjuvant treatment is determined by the risk of recurrence, the estrogen-receptor status of the primary tumor, and menopausal status. Tamoxifen, an estrogen-receptor antagonist, is presently the preferred choice of adjuvant hormonal treatment for all women with estrogen-receptor-positive breast cancer. It is supplemented in selected cases by cytotoxic chemotherapy. Premenopausal women may also benefit from treatment with a gonadorelin analog or ovarian ablation. Treatment with tamoxifen delays the growth of metastases and increases survival. If tolerated, treatment should be continued for 5 years. Tamoxifen also lowers the risk of tumor formation in the other breast. Anastrozole is also licensed for the adjuvant treatment of estrogen-receptor-positive early breast cancer in...
Therapeutically, estrogens are used in oral contraceptives, as replacement therapy during the menopause, and for treatment of some malignancies. Among the available substances are estradiol and its derivatives, ethinylestradiol (the estrogen in most of the estrogen-containing birth control pills), mestranol, estrone, conjugated equine estrogens, polyestradiol, estriol, fosfestrole, chlorotri-anisen, and epimestrol.
Estrogen is rarely used to treat prostate cancer because of its adverse reactions but is occasionally used to treat breast cancer in postmenopausal women if no other options are available. In prostate cancer, an estrogenic agent such as DES works by inhibiting the hypothalamic-pituitary system through a negative feedback (shut off) mechanism. A shortage of testosterone DHT reaching the cells signals of an increased production of testosterone by the testes (some of which will reach cells and occupy receptors) which results in a fall of output of LH from the pituitary of LH and a subsequent decrease in testosterone synthesis by the testes (an outcome known as chemical castration ).
Mixed evidence, however, has been described in women. Raloxifene improved flow-mediated, endothelium-dependent vasodilation in postmenopausal women (Sarrel et al. 2003) to an extent similar to that of HT (Colacurci et al. 2003 Saitta et al. 2001). Other investigators, however, have been unable to detect any effect of raloxifene (Ceresini et al. 2003 Griffiths et al. 2003). Flow-mediated vasodilation has been described for droloxifene (Herrington et al. 2000), while a neutral effect on vascular reactivity has been described for ospemifene, a more recent SERM (Ylikorkala et al. 2003).
The time of the month, a period, her monthlies there are many expressions for a woman's menstrual cycle (a recurring cycle (beginning at menarche and ending at menopause) in which the endometrial lining of the uterus prepares for pregnancy if pregnancy does not occur the lining is shed at menstruation), and it is marked by mood changes, tension, stomach cramps, cravings for certain foods etc.
In a recent British case-control study, treatment information on 813 patients who had endometrial cancer after being diagnosed with breast cancer was compared to 1067 control patients with breast cancer but no subsequent endometrial cancer. The use of tamoxifen was associated with an increased risk of endometrial cancer (odds ratio 2.4). Based on the concluding information, the majority of researchers recommended that women taking tamoxifen should be carefully evaluated from an endometrial point of view, both before starting treatment and periodically during its use, and that a physician be consulted in the case of abnormal vaginal bleeding. This risk should be considered for both premenopausal and postmenopausal women for at least 5 years after the last treatment (Swerdlow et al. 2005).
Cancer (breast and prostate cancer in particular), heart disease (antioxidant activity), osteoporosis, menopause, cognitive function and diabetes are major points of focus for the potential health benefits of phytoestrogens. Much interest has been Due to their positive (but weak) estrogenic activity, phytoestrogens have been advocated as a substitute for estrogen replacement therapy to prevent or reduce the symptoms of menopause. This concept is supported by the observation that menopause appears to be much less of a problem for women in countries where high amounts of soy are consumed. For example, in Japan, postmenopausal women reportedly suffer much less from night sweats and hot flashes than their U.S. and U.K. counterparts.
The primary estrogen in premenopausal women is 17-b-estradiol (E2), which is synthesized by developing ovarian follicles. Estradiol is oxidized to estrone (E1) and then to estriol (E3). Estrone is also produced in peripheral tissues by aromatization of androstenedione, an androgen precursor that is produced by both the ovaries and the adrenal glands after the menopause, estrone produced in this way becomes the predominant estrogen. All of the estrogens are sulfated and glucuronidated before excretion. For injectable formulations used in estrogenic hormone replacement therapy, various esters of beta-estradiol have been most widely used. As noted above, 17-b-estradiol has hardly been used by the oral route, except in micronized form. The micronized product is also available in the form of an intranasal spray for the treatment of menopausal symptoms this can give rise to mild irritation, leading to sneezing (1).
Pseudoephedrine is believed to promote a dangerous bowel disease called ischemic colitis, particularly in women around the time they go into menopause. A case report indicates that taking pseudoephedrine with serotonin reuptake inhibitor antidepressants may create a medical emergency called serotonin syndrome. Typical signs of that condition are hyperactivity, confusion, nervousness, vomiting, fast heartbeat, excessive body temperature, shivering, tremors, weakness, or losing consciousness. Caution is advised about using pseudoephedrine shortly after receiving vaccinations, which temporarily increase body temperature. Nonetheless, in the 1980s research on more than 100,000 individuals using prescription pseudoephedrine found no hospitalizations caused by the drug.
Cimicifuga racemosa has been used to relieve symptoms of menopause, although with little evidence of efficacy (4). A 47-year-old woman took an extract of C. racemosa for 1 week to treat menopausal symptoms she developed jaundice and raised liver enzymes (5). No other causes of liver damage were found. She required liver transplantation.
Methyltestosterone is a synthetic analog of testosterone that possesses all of the properties of testosterone, exhibiting stimulatory action on the development of male sex organs and secondary sex characteristics, although it is not degraded by enzymes in the gastrointestinal tract, and therefore it can only be taken orally. It is used for the same indications as testosterone for sexual underdevelopment, functional problems of the reproductive system, and the vascular nerve disorders associated with climacteric problems in men. It is also used for dysfunctional uterine bleeding in premenopausal and menopausal women as well as for breast and ovarian cancer. Synonyms of this drug are androral, testoral, oraviron, and others.
In 1986, Mendelson and colleagues (40) reported that marijuana smoking suppressed luteinizing hormone levels in normal women but not in menopausal women (41). Barnett et al. (42) showed that testosterone levels were depressed both after smoking one marijuana cigarette and after intravenous infusion of THC. This antiandrogenic effect of marijuana appears to occur through action on the hypothalamic-pituitary-
There is no doubt that steroids have behavioural effects. Given clinically in the therapy of inflammatory conditions, the glucocorticoids are considered to produce euphoria, followed after prolonged or higher dosing by depression and, of course, when we are stressed the corticocosteroids pumped out by the adrenal cortex easily enter the brain and may initiate some of the behavioural response. In women the premenstrual syndrome (irritability, depression and anxiety) is thought to be associated in some way with progesterone since not only does its concentration rise then fall during that time but in post-menopausal women the use of sequential oestrogen and progestogen hormone replacement therapy (HRT) shows that similar mood changes accompany only the addition of progestogen. More specifically, in women with epilepsy while the incidence of seizures decreases when plasma progesterone is high, it increases during the immediate premenstrual period as progesterone levels fall, rather as...
Many chemicals can commonly surface in an Ecstasy pill. In Memphis, for example, reported additives include metham-phetamine and mescaline, and in Los Angeles, Ecstasy is often laced with dextromethorphan (DXM) or paramethoxyampheta-mine (PMA). In Seattle, though, the trend is not lacing MDMA with other substances, but fraudulently substituting another drug entirely. In one reported batch, for instance, the confiscated Ecstasy pills turned out not to be Ecstasy at all, but rather hormone replacement pills. While certainly causing less harm than Ecstasy, a pill full of estrogen is probably not what many people had in mind when they bought those tablets. Additionally, the estrogen in hormone replacement therapy pills may cause an interaction with birth control pills, decreasing their ability to block pregnancy.
Angelica sinensis, known in China as dong quai'' or dang gui,'' contains antioxidants (8), inhibits the growth of cancer cells in vitro (9) and stimulates immune function in experimental animals (10). It has been used to treat amenorrhea (11) and menopausal hot flushes (12), and to reduce pulmonary hypertension in patients with chronic obstructive pulmonary disease (13).
One expert in the USA (PA Ganz, cited in 67r) has publicly defended the safety of tamoxifen on the grounds that some of its supposed adverse effects may in fact have other causes. It is a difficult argument to follow, since she postulates that various of the unwanted effects referred to are in fact menopausal however, these are largely likely to be inevitable consequences of the very changes that treatment with tamox-ifen is intended to induce, i.e. suppression of estrogenic effects. Virtually the opposite belief can be derived from a Canadian study, which showed that 25 women taking tamoxifen were diffident about attributing adverse events to the drug, and therefore tended to under-report adverse effects (68cr). Menopause-like problems with these drugs are clearly likely to persist unless or until more selective SERMs become available, e.g. substances that act exclusively on the breast tumor. Endometrial polyps are common during postmenopausal treatment with tamoxifen, and up to 3...
Letrozole, an oral aromatase inhibitor, is now being advanced as an alternative to tamox-ifen for first-line treatment in postmenopausal women with advanced breast cancer (63c). In one randomized study of 970 patients given letrozole 2.5 mg day or tamoxifen 20 mg day the therapeutic results were at least equivalent and the time to progression was significantly longer with letrozole than tamoxifen (median 41 vs. 26 weeks). Both drugs were well tolerated, but this aspect has yet to be documented in detail.
In contrast to other protein-bound drugs for which a loading dose is given to achieve rapid steady-state concentrations, a slow and stepwise increase in thyroid hormone replacement therapy is advisable. This is preferred mainly to avoid sudden cardiac adverse effects, especially in older patients with long-standing myxedema. Moreover, since thyroid hormone substitution can change the metabolic clearance of this drug, steady-state concentrations are obtained only after several months (SEDA-6, 363).
From PMS To PPD
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