The effect of alpha-tocopherol on premenstrual symptomatology: a double-blind study. II. Endocrine correlates

Women's health: selected topics

Complementary and alternative medicine (CAM) therapies have become increasingly popular for the treatment of a variety of conditions. The World Health Organization has recognized the value of traditional healing techniques, which are classified as CAM, for 30 years. In the United States nearly 50% of women use CAM for common medical conditions, significantly more than men. This pattern is frequently seen in the treatment of women's health conditions such as infertility, premenstrual syndrome, and menopause. This article provides an integrative approach for conditions commonly encountered in the primary care setting among women, discusses alternative therapies used to treat these health conditions, and provides an evidence-based summary of recommendations based on a review of the literature.

Malon dialdehyde, nitrite and adrenomedullin levels in patients with premenstrual syndrome

OBJECTIVE

To assess the levels of malon dialdehyde (MDA); a lipid peroxide product, total nitrite; a stabile product of nitric oxide (NO), and adrenomedullin (AM), to determine whether their levels are altered in premenstrual syndrome (PMS) and to search for their possible pathophysiological role in this peculiar syndrome.

STUDY DESIGN

Twenty-one patients aged between 28 and 37 years, who had regular menses for at least six previous cycles, and were in general good health condition, were taken into the study. Blood samples were obtained from each patient at the 3rd and 21st day of their menstrual cycles. AM, nitrite, MDA and estradiol levels have been assessed in these samples for each patient.

RESULTS

No statistically significant difference in terms of age, parity and body mass index was detected among groups (P > 0.05). Nitric oxide levels were higher on the 3rd day, compared to 21st day in the study group, and this difference was statistically significant (P < 0.05). In the study group, 21st day AM levels were significantly higher when compared to the control group (P < 0.05).

CONCLUSION

Even though various stress symptoms are present in PMS, there is no change in the levels of MDA, an oxidative distress indicator but AM and NO may have a pathophysiological role on this enigmatic disease.

DHEAS as a new diagnostic tool

Dehydroepiandrosterone sulfate (DHEAS) is a 19-carbon steroid, situated along the steroid metabolic pathway. It is the most abundant circulating steroid hormone in the body and can be converted to either androgens or estrogens. Their physiological and pathological functions have not yet been fully identified. Serum DHEAS concentrations peak at around age 25 years and then decline steadily over the following decades. Due to its long half-life and high concentration in the blood, the levels of DHEAS remain the same 24 h a day. This makes DHEAS a very interesting new diagnostic tool for both scientific research and clinical diagnostics. Moreover, circulating concentrations of DHEAS can be changed by many factors, such as endogenous production, hormone supplementation, many kinds of drugs, and many types of disease states. As research moves forward to better understand the relationships of DHEAS with health and disease, it is essential that studies should be designed to control for the influence of many factors on serum DHEAS concentrations.

The influence of hormones and pharmaceutical agents on DHEA and DHEA-S concentrations: a review of clinical studies

Low endogenous levels of dehydroepiandrosterone (DHEA) and/or its sulfoconjugated derivative DHEA-S have been associated with diseases such as lupus, cancer, and diabetes. Circulating concentrations of DHEA and DHEA-S resulting from endogenous production or hormone supplementation may also be relevant in psychiatric illness. Drugs may significantly increase or decrease circulating concentrations of these adrenal androgens by various mechanisms. Some agents, such as dexamethasone, affect the HPA axis by inhibiting ACTH and therefore decrease DHEA and DHEA-S concentrations. Central nervous system agents, including carbamazepine and phenytoin, induce the P450 enzymes that metabolize DHEA and DHEA-S and therefore decrease circulating concentrations of these hormones. Danazol alters the ratio between DHEA and DHEA-S by inhibiting sulfatase. As research moves forward to better understand the relationships of these adrenal androgens with health and disease, it is essential that studies be designed to control for the influence of administered pharmaceuticals on DHEA and DHEA-S.

Evaluation and Management of Premenstrual Syndrome and Premenstrual Dysphoric Disorder

OBJECTIVE

To review premenstrual disorders, their varied symptoms, possible etiology, and treatment options.

DATA SOURCES

Published articles identified through MEDLINE (1966-2001) using the search terms premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) and the additional terms treatment and etiology. Additional references were identified from the bibliographies of the retrieved articles.

DATA SYNTHESIS

PMS refers to a group of menstrually related disorders that are estimated to affect up to 40% of women of childbearing age. The varied symptoms of PMS include mood swings, tension, anger, irritability, headache, bloating, and increased appetite with food cravings. PMS symptoms occur during the luteal phase of the menstrual cycle and remit with the onset of menstruation or shortly afterward. Approximately 5% of women with PMS suffer from PMDD, a more disabling and severe form of PMS in which mood symptoms predominate. Because no tests can confirm PMS or PMDD, the diagnosis should be made on the basis of a patient-completed daily symptom calendar and the exclusion of other medical disorders. The causes of PMS and PMDD are uncertain, but are likely associated with aberrant responses to normal hormonal fluctuations during the menstrual cycle. For most women, symptoms can be relieved or reduced through lifestyle interventions, such as dietary changes and exercise, and drug therapy with hormonal or psychotropic agents. For PMDD, selective serotonin reuptake inhibitors have recently emerged as first-line therapy. Certain dietary supplements, including calcium, also may be an option for some women.

CONCLUSION

PMS and PMDD are complex but highly treatable disorders. Pharmacists can improve the recognition and management of these common conditions by providing patient education on premenstrual symptoms and counseling women on lifestyle interventions and pharmacotherapy to relieve their discomfort.

Urinary incontinence: treatments, interventions, and outcomes

The central theme of this article is the development of clinical outcomes and interventions by CNSs to enhance the quality of care provided by nurses. This was done using findings from three funded research projects conducted by the authors. The outcomes begin with measurable nursing diagnoses and continue with searches for remedial risk factors, assessment, and remedies. The interventions encourage responsible behaviors by elders that are individualized prevention and/or treatments for a given diagnosis. A brief synopsis of the research results is included.

Improving elders' continence state

A 6-month study was conducted to assess the effects that noninvasive self-managed interventions on 12 remediable risk factors had on elder's urinary continence status. Each remediable risk factor was linked with a criterion meeting normal and if not normal, one or more interventions. Continence history assessments were conducted monthly on 31 elders (M age = 67.65 years). After the first assessment, elders were identified as continent, incontinent or at risk for loss of continence. At the end of the 6 months, 9 of the 11 incontinent elders moved to the at-risk group and the other 2 remained incontinent, and 12 of the 20 at-risk elders became continent. Both the elders who were initially at risk and those who were incontinent had a statistically significant reduction in the number of remediable risk factors reported at the end of the study period. The assessments and interventions are useful.

Problems of aging: urinary incontinence prevention

This exploratory study focused on identification of risk factors, the criteria establishing risk, and associated preventive strategies for diagnosis and treatment of urinary incontinence. Sixty-eight women were assessed for actual and potential urinary incontinence. Data collected each month included demographics, medical diagnoses, medications, environmental features, mobility, mental status, and presence or absence of eleven probable risk factors drawn from an extensive review of the literature. Women learned one or more noninvasive treatment strategies linked to their risks. Pretreatment analysis identified 55 women at risk and 13 as incontinent. Posttreatment, 9 were incontinent (1 at-risk woman became incontinent). Greater numbers of risk factors were experienced by the incontinent women. Posttreatment, 7 of the incontinent women eliminated from 1 to 5 risk factors. Risk-factor identification and correction are essential for concerted prevention efforts. The results are clinically important.

The treatment of late luteal phase dysphoric disorder

This mini-review provides a comprehensive discussion of the management of the late luteal phase dysphoric disorder (LLPDD). The various treatments will be described with particular attention to their efficacy and the nature of side effects. These include: psychoactive drugs (lithium, anxiolytics, antidepressants), nutritional agents (L-tryptophan, Vitamin B6, prostaglandins precursors and inhibitors), dopamine agonists, diuretics, antihypertensives, hormonal interventions (gonadotrophin releasing hormone analogues, oestradiol, tamoxifen, progesterone, danazol, and oral contraceptives). Less attention has been given to non-pharmacologic approaches such as diet, exercise and psychotherapy. The availability of an operational definition of LLPDD in the DSM-III-R and the improvement in research methodology has provided a clearer direction for clinical management and for future investigations.

Fibrocystic breast disease: pathophysiology, pathomorphology, clinical picture, and management

The pathophysiology of fibrocystic breast disease is determined by estrogen predominance and progesterone deficiency that result in hyperproliferation of connective tissue (fibrosis), which is followed by facultative epithelial proliferation; the risk of breast cancer is increased twofold to fourfold in these patients. The clinical correlate of fibrocystic disease is reflected by breast and axillary pain or tenderness in response to development of fibrocystic plaques, nodularity, macrocysts, and fibrocystic lumps. The disease progresses with advancing premenopausal age and is most pronounced in women during their 40s. Fibrocystic changes regress during the postmenopausal period. Medical treatment of fibrocystic disease is accomplished: by suppression of ovarian estrogen secretion with a low-estrogen oral contraceptive, whereby the action of estrogen on breast tissues is opposed by the oral contraceptive's progestin component (19-nortestosterone derivatives), or by cyclic administration of a progestogen (progesterone, medroxyprogesterone acetate) that modulates the mammary effects of estrogen. These treatment modalities are equally as effective as or superior to danazol therapy, which entails side effects in the majority of patients. Adjuvant therapy of fibrocystic breast disease with vitamin E is of value in patients with borderline or abnormal lipid profiles (low plasma levels of high-density lipoprotein and high plasma levels of low-density lipoprotein). With thorough diagnostic evaluation, appropriate medication, and close follow-up, treatment success can be achieved in almost every patient. Needle aspiration biopsy should be performed in patients with macrocysts and whenever clinical, ultrasonic, and/or mammographic examinations are suspicious for carcinoma. Patients at high risk of breast cancer (breast cancer in mother and/or sister) should have clinical examinations at 4- to 6-month intervals and mammography every 1 to 2 years; needle aspiration should be performed when the slightest suspicion arises. Fibrocystic breast disease is not a "harmless nondisease" but a distinct clinical entity that requires treatment to bring about relief to the patient, to reduce the incidence of breast surgical procedures, and to diminish the risk of breast cancer.