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The main advantage of the triphasic oral contraceptive (OC) is its reduced corticosteroid content, which is accompanied by a reduction in metabolic impact. Triphasic pills differ according to their components and according to whether or not their estrogen dose is constant. The Triella pill has a constant dose of 35 mcg ethinyl estradiol (EE) and a dose of norethisterone that increases from .50 to 1 mg, while Triquilar-Trinordiol mimics the preovulatory estrogen peak while also varying the progestin content. In a study of 22,728 cycles, the Pearl index was only .06/100 woman years for triphasic pills. Comparisons with existing monophasic pills indicate that triphasics may offer improved cycle control, but the fact should be emphasized to patients that cycle control is an inappropriate criterion for choice of pills. Metabolic effects or possible carcinogenic effects are more important qualities. Triphasic pills have been found to improve acne, not to affect weight or blood pressure, and to reduce the frequency of headaches, nervousness, and breast tenderness. Studies have shown that triphasics containing levonorgestrel produce minimal effects on lipid metabolism, while less rigorous studies on triphasics containing norethisterone have also yielded favorable results. It is true however that knowledge of the relationship between alterations in plasma cholesterol caused by Triella use and the etiology of certain diseases remains incomplete. Low dose triphasic pills appear to have fewer deleterious effects on glucose metabolism than higher dose pills, but they are not entirely without effect and should not be prescribed for women at risk of developing diabetes. Studies examining modifications of the intima and coagulation factors have given reassuring results, and neither triphasics with levonorgestrel nor those with norethisterone modify the blood pressure. Triphasics entail a reduction in the levels of estradiol and testosterone and a slight increase of plasma renin activity but no modification in plasma aldosterone. The subtle effects on the gonodotropic axis are considered especially fitting for young women in whom post-pill ovulatory function is preserved. Endometrial biopsies show that the state of the endometrium with OC use is not well understood and highly variable. The triphasic pill approaches as closely as possible the normal physiology of the endometrium while still suppressing ovulation.
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PMID:[The triphasic pill]. 1228 Feb 9

Many studies show that low-dose OCs have little adverse effect on carbohydrate metabolism and are safe for healthy women, women with a history of gestational diabetes, and women with insulin-dependent diabetes to use. In fact, large epidemiologic studies indicate that OCs, even the high-dose OCs (=or 50 mcg) for long periods, do not increase the risk of diabetes. There is some evidence indicating that OC use does not heighten the progression of diabetic retinopathy, nephropathy, or cardiovascular complications among women with insulin-dependent diabetes. There is no significant difference in carbohydrate metabolism among the different OC formulations. One must carefully consider the risk:benefit ratio of OC use in diabetic women since pregnancy has serious consequences for both mother and fetus. Cardiovascular complications in OC users do not originate from atherogenesis. The androgenic properties of the progestin in low-dose OCs and their effect on lipids are inconsequential for later development of coronary atherogenesis. The estrogen in OCs may protect against atherosclerosis, particularly among women at high risk of atherosclerosis. Former OC users are not at an increased risk of coronary heart disease, stroke, or other heart disease. Lipid changes in OC users tend to remain within the normal range and return to pretreatment values during the pill-free week. All OCs suppress gonadotropins and subsequent ovarian androgen production. They partially suppress androgen production by the adrenals as well. This suppression from two fronts outweighs any androgenic action of the progestin alone. Further, androgenic action probably cannot overpower the estrogen effect. The dose of levonorgestrel used in OCs is too low to express androgenic effects. Since OCs suppress androgen production, all OCs tend to improve acne. OCs reduce free testosterone and increase sex hormone binding globulin levels.
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PMID:Metabolic effects of oral contraceptives: fact vs. fiction. 1232 11

Dermatologists may commonly see skin lesions that reflect an underlying endocrine disorder. Identifying the endocrinopathy is very important, so that patients can receive corrective rather than symptomatic treatment. Skin diseases with underlying endocrine pathology include: thyrotoxicosis; hypothyroidism; Cushing syndrome; Addison disease; acromegaly; hyperandrogenism; hypopituitarism; primary hyperparathyroidism; hypoparathyroidism; pseudohypoparathyroidism and manifestations of diabetes mellitus. Thyrotoxicosis may lead to multiple cutaneous manifestations, including hair loss, pretibial myxedema, onycholysis and acropachy. In patients with hypothyroidism, there is hair loss, the skin is cold and pale, with myxedematous changes, mainly in the hands and in the periorbital region. The striking features of Cushing syndrome are centripetal obesity, moon facies, buffalo hump, supraclavicular fat pads, and abdominal striae. In Addison disease, the skin is hyperpigmented, mostly on the face, neck and back of the hands. Virtually all patients with acromegaly have acral and soft tissue overgrowth, with characteristic findings, like macrognathia and enlarged hands and feet. The skin is thickened, and facial features are coarser. Conditions leading to hyperandrogenism in females present as acne, hirsutism and signs of virilization (temporal balding, clitoromegaly).A prominent feature of hypopituitarism is a pallor of the skin with a yellowish tinge. The skin is also thinner, resulting in fine wrinkling around the eyes and mouth, making the patient look older. Primary hyperparathyroidism is rarely associated with pruritus and chronic urticaria. In hypoparathyroidism, the skin is dry, scaly and puffy. Nails become brittle and hair is coarse and sparse. Pseudohypoparathyroidism may have a special somatic phenotype known as Albright osteodystrophy. This consists of short stature, short neck, brachydactyly and subcutaneous calcifications. Some of the cutaneous manifestations of diabetes mellitus include necrobiosis lipoidica diabeticorum, diabetic dermopathy, scleredema adultorum and acanthosis nigricans.
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PMID:Cutaneous manifestations of endocrine disorders: a guide for dermatologists. 1268 37

Acne and body hair are both cutaneous responses to androgenic stimulation. They are normal events in adolescent girls. There is considerable variation in the evolution of the two conditions. The sebaceous gland is exquisitely sensitive to androgens, and acne appears with the onset of puberty, peaks in prevalence in the teenage years and gradually improves thereafter. Hair growth on the face, trunk and limbs develops more slowly and generally peaks in the 20s. Indications for endocrine investigation include very severe acne, onset of acne and hirsuties in the very early stage of puberty (Tanner stage 3) and systemic virilism. Treatment for acne and hirsuties can be either topical or systemic. The choice of therapy is based on the severity of the disease rather than the results of endocrine investigation. Further, since PCO is related to impaired glucose tolerance, advice relating to lifestyle changes should be offered to prevent the development of diabetes.
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PMID:Acne and hirsuties in teenagers. 1275 31

We report a rare case of virilizing adrenocortical adenoma complicated with Cushing's syndrome, thyroid papillary carcinoma and hypergastrinemia. A 45-year-old woman had a history of amenorrhea for 10 years, hypertension for 8 years, and diabetes mellitus for 3 years. Physical examination showed a masculinized woman with severe hirsutism, male-like baldness, deep voice, acne in the precordia, and clitorism. Plasma testosterone, DHEA-S and urinary 17-KS were high, and plasma cortisol level was it at the upper limit of the normal range, but it did not show a diurnal rhythm nor was suppressed by 2 and 8 mg of dexamethasone. Abdominal CT scan showed a left adrenal tumor (4.5 cm in size). Adrenal scintigram revealed uptake of the tracer on the left side, and plasma cortisol concentration was high in a blood sample from the left adrenal vein. Left adrenalectomy was performed. Histopathological features of resected adrenal tumor were consistent with those of adrenocortical adenoma, consisting of tumor cells with eosinophilic compact cytoplasm. Immunohistochemical staining for steroidogenic enzymes showed reactivity for P450sec, 3 beta-HSD, P450c17, P450c21 and P450c11. Plasma testosterone and cortisol levels decreased to the normal range postoperatively. The patient was also found to have a papillary thyroid carcinoma and hypergastrinemia. Our patient is a rare case of virilizing adrenocortical adenoma associated with Cushing's syndrome, thyroid papillary carcinoma, and hypergastrinemia.
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PMID:Virilizing adrenocortical adenoma with Cushing's syndrome, thyroid papillary carcinoma and hypergastrinemia in a middle-aged woman. 1280 38

Adolescence is a period of active growth and development-physical, sexual, social and emotional. There are wide normal variations between the time of onset and the attainment of full maturity. Many adolescents present few if any problems during this potentially turbulent period, and make the necessary adjustments without undue stress to themselves, their family or their friends. Problems in growth and hormonal balance, presenting as short and tall teenagers, menstrual irregularities, obesity and acne are discussed. The impact of chronic disease-diabetes, convulsive disorders and rheumatic carditis-is a challenge to the skills and patience of the practising physician.
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PMID:PROBLEMS OF ADOLESCENCE. 1415 31

This article reviews current literature regarding polycystic ovary syndrome (PCOS) and health-related quality of life (HRQoL), as well as examining how some of the manifestations of PCOS affect HRQoL. The only quantitative study was performed in adolescent girls. It used a well-validated instrument and showed that HRQol was worse in those with PCOS in the areas of general health perceptions, behavior, physical functioning and family activity. No comparable study exists for adults with PCOS. However, qualitative psychological studies have demonstrated higher levels of depression, psychological and psychosexual morbidity and an increased response to stress in women with PCOS compared with controls. Low self-esteem, decreased social activity and less romantic contentment were reported in women with PCOS. Weight and hirsutism consistently caused more concern than menstrual problems or infertility. The symptoms associated with PCOS, namely hirsutism, acne, diabetes mellitus and obstructive sleep apnea syndrome (OSAS) were all reported to reduce HRQoL in separate studies. Encouragingly, treatment for acne and OSAS improved the HRQoL, although treatment for hirsutism did not. Quantitative studies on the effect of PCOS on HRQoL and the benefit of treatments need to be conducted.
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PMID:The effect of polycystic ovary syndrome on health-related quality of life. 1471 May 85

Reactions in leprosy causing nerve function impairment (NFI) are increasingly treated with standardized regimens of corticosteroids, often under field conditions. Safety concerns led to an assessment of adverse events of corticosteroids, based on data of three trials studying prevention of NFI (the TRIPOD study). A multicentre, randomized, double-blind placebo-controlled trial was conducted in leprosy control programmes in Nepal and Bangladesh. Treatment was with prednisolone according to fixed schedules for 16 weeks, starting in one trial with 20 mg/day (prophylactic regimen: total dosage 1.96 g) and in the other two trials with 40 mg/day (therapeutic regimen: total dosage 2.52 g). Minor adverse events were defined as moon face, fungal infections, acne, and gastric pain requiring antacid. Major adverse events were defined as psychosis, peptic ulcer, glaucoma, cataract, diabetes and hypertension. Also, the occurrence of infected plantar, palmar, and corneal ulceration was monitored, together with occurrence of TB. Considering all three trials together, minor adverse events were observed in 130/815 patients (16%). Of these, 51/414 (12%) were in the placebo group and 79/401 (20%) in the prednisolone group. The relative risk for minor adverse events in the prednisolone group was 1.6 (P = 0.004). Adverse events with a significantly increased risk were acne, fungal infections and gastric pain. Major adverse events were observed in 15/815 patients (2%); 7/414 (2%) in the placebo group and 8/401 (2%) in the prednisolone group. No major adverse events had a significantly increased risk in the prednisolone arm of the trials. No cases of TB were observed in 300 patients who could be followed-up for 24 months. Standardized regimens of corticosteroids for both prophylaxis and treatment of reactions and NFI in leprosy under field conditions in developing countries are safe when a standard pre-treatment examination is performed, treatment for minor conditions can be carried out by field staff, referral for specialized medical care is possible, and sufficient follow-up is done during and after treatment.
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PMID:Adverse events of standardized regimens of corticosteroids for prophylaxis and treatment of nerve function impairment in leprosy: results from the 'TRIPOD' trials. 1475 May 77

PCOS is a metabolic syndrome that exists throughout the world with much clinical heterogeneity. PCOS is now appreciated as encompassing two interrelated metabolic phenomena--insulin resistance and hyperandrogenism. Patients present with oligo-amenorrhea and clinical hyperandrogenism, and the diagnosis is based on clinical grounds with few laboratory tests necessary. Because patients are at higher than normal risk for diabetes, glucose intolerance, and hyperlipidemia, and perhaps at higher risk for coronary heart disease, newly diagnosed patients with PCOS should be evaluated for glucose intolerance and hyperlipidemia. The cornerstone of therapy today includes weight management, and further therapeutic intervention is focused on reproductive and cardiovascular health and treatment of insulin resistance. Clinical case continued The 17-year-old mentioned in the beginning of this article probably does have PCOS. She fits the clinical criteria: oligo-ovulation and hyper-androgenism (the acne and hirsutism). In addition, she is obese, which is also associated with PCOS. Her TSH and prolactin were normal, and as her presentation was not suggestive of an adrenal tumor or congenital adrenal hyperplasia (she had mild hirsutism, and those diagnoses are associated with more severe hyperandrogenism), no further laboratory evaluation was deemed necessary. Once the diagnosis was made, she was screened for lipid abnormalities and for glucose intolerance. Her LDL was 150, HDL 35; oral glucose tolerance test (OGTT) was normal. A pregnancy test was negative, and she was started on OCPs. Devoting herself to exercise and dietary change, she lost 10 pounds in her first 3 months after diagnosis. Her hirsutism and acne have improved with the OCPs and weight loss, and her menses are regular. She has elected to defer oral insulin sensitizers until her weight loss has stabilized. Findings PCOS is common in reproductive-aged women. Diagnosis is clinical and is supported by lab findings; there is significant clinical heterogeneity. Insulin resistance is likely central to the pathophysiology along with androgen excess. Health implications include infertility, diabetes, endometrial cancer, hyperlipidemia, and possibly coronary heart disease. Treatment is evolving and includes weight loss, OCPs, and insulin sensitizers.
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PMID:Polycystic ovary syndrome: a review for primary providers. 1502 92

Islet transplantation can deliver stable glycemic control, relief from recurrent severe hypoglycemia, and insulin independence. Accessing the portal vein via the percutaneous hepatic approach carries the risk of bleeding, and the infusion of islets a risk of portal vein thrombosis. In the long term, common minor problems with immunosuppression are mouth ulcers, diarrhea, and acne. Longer-term risks include malignancy and serious infection, both rare to date in clinical islet transplantation. Sensitization to donor antigens may also occur. The long-term diabetes complications may stabilize, but of this aspect little is known to date. In the short term, there may be some elevation of serum cholesterol and blood pressure, in some patients there has been a decline in renal function, and in a few, acute retinal bleeds. For most, improvement in glucose control with resolution of glycemic lability and hypoglycemia has been a net benefit.
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PMID:Risks and side effects of islet transplantation. 1526 74


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