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Synthetic progestins derived from nortestosterone provide a promising contraceptive alternative for women with contraindications for estrogens. Progesterone and synthetic progestins reduce vasodilatation and edema induced by estrogens and stop estrogen-dependent cellular multiplication in target tissue. Progestins have 2 kinds of contraceptive affect: antigonadotropic action at sufficient doses, and peripheral action at lower doses. The cervical mucus is modified in composition and volume, becoming hostile to sperm; the endometrial mucus atrophies; and tubal motility is slowed. High dose progestins are administered from the 5th or 10th to the 25th cycle day, with the earlier date preferred for women with shorter cycles. They are an ideal method for women with endometrial hyperplasia or benign breast disease or histories of breast or uterine cancer, as well as for women over 40 with dysovulatory cycles. Contraindications to high dose progestins include obesity, hypertension, lipid metabolic anomalies, and diabetes. Low dose progestin-only pills are administered at the exact same time each day including during menstruation. They are attractive for some women because they contain no estrogen, a reduced progestin dose causing fewer headaches and less somnolence, and fewer metabolic effects. Low dose progestins are indicated for lactating women, those with contraindications to estrogens such as obesity, hypertension, hyperlipidemia, and diabetes, and those with renal or cardiac insufficiency with valvulopathy. Low dose progestins are also indicated for nulliparas and other women for whom IUDS are contraindicated. Women using low dose progestins should never take drugs that act as enzymatic inductors, which speed hepatic degradation of steroids and reduce their efficiency. A resulting pregnancy is likely to be extrauterine because of slowed tubal transport. The failure rate of low dose progestins ranges from .9-3%, with higher failure rates among younger women. About 30% of users initially experience spotting, which despite its usual disappearance after 2-3 months of use is the most common reason for discontinuing the method. Low dose progestins have no metabolic or vascular effects, but they may cause a relative hyperestrogenism is some users. Other modes of administration of progestin contraception include continuous high doses, never justified solely for contraception. Trimonthly injections of medroxyprogesterone acetate of norethindrone enanthate provide contraception through a long lasting antigonadotropic effect. Metrorrhagia and amenorrhea are among possible side effects. The method is used primarily in developing countries where its ease of use is a major advantage. Subcutaneous implants releasing continuous doses of levonorgestrel provide contraceptive protection for over 5 years. The cumulative failure rate is 1.7 at 5 years. Metabolic tolerance is good. The major side effect is menstrual irregularity.
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PMID:[Progestational contraception]. 365 94

Risk factors for the development and rupture of intracranial saccular (berry) aneurysms were identified in a case-control study of autopsy subjects. The development of berry aneurysms was positively correlated with increased frequencies of systemic arterial hypertension (p less than 0.001), cerebral artery atherosclerosis (p less than 0.05), and marked asymmetry of the cerebral vessels comprising the circle of Willis (p less than 0.005). In addition, patients with berry aneurysms more frequently had histories of persistent headache (p less than 0.001), pregnancy-induced hypertension (p less than 0.01), long-term use of analgesics (p less than 0.001), especially aspirin (p less than 0.05), and a family history of stroke (p less than 0.05). Factors associated with a decreased risk of berry aneurysms included treatment with insulin to control diabetes mellitus (p less than 0.005), leanness (p less than 0.05), chronic pancreatitis (p less than 0.001), malignant tumors (p less than 0.001), and moderate or severe coronary or renal atherosclerosis (p less than 0.05). Rupture of berry aneurysms was positively correlated with size (p less than 0.05) and the presence of multiple aneurysms (p less than 0.005), but also with long-term analgesic usage (p less than 0.05), excessive ethanol consumption (p less than 0.01), and fatty metamorphosis of the liver (p less than 0.01). The factors that predispose to rupture of berry aneurysms are interrelated in the sense that several of them are known to cause a decrease in the synthesis of prostaglandin E, whereas one of the factors that appears to be protective has the opposite effect. Marked and abrupt lowering of serum prostaglandin levels would cause dilatation of cerebral vasculature and increased cerebral blood flow; in the setting of hypertension, focal defects in cerebral arteries could develop, leading to the formation and subsequent rupture of berry aneurysms.
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PMID:Risk factors for the development and rupture of intracranial berry aneurysms. 401 70

A patient with adult-onset diabetes mellitus developed an oculomotor palsy with pupillary sparing. Five days after her initial evaluation, she presented in a confused state with a complete oculomotor palsy. Computed cranial tomography revealed a chronic subdural hematoma. We recommend that noninvasive radiographic intracranial investigation be considered in elderly patients with adult-onset diabetes mellitus who present with headache and pupil-sparing oculomotor palsy.
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PMID:Oculomotor palsy with pupillary sparing in a patient with chronic subdural hematoma. 406 48

There have been numerous accounts of women on ovulation inhibitors developing hypertension or reactifying or intensifying previous hypertension. Concerning frequency of significant hypertension in pill users, there are reports varying from .66% (or even 0%) to 19%. The time interval between start of medication and manifestation of hypertension also varies according to different sources from 7 days to 5 years, with the critical point usually around 6-8 weeks. Degree of hypertension after ovulation inhibitors ranges from mildly significant increases in systolic and/or diastolic blood pressure to malignant hypertension with irreversible kidney insufficiency. Early observable symptoms of hypertension include migrainelike headaches and rapid weight gain (sodium and water retention). After discontinuation of the medication, normal blood pressure is attained either within a few days or after 6-8 months. If normalization of blood pressure does not occur spontaneously there may be other causes (e.g., secondary vascular disorders). Concerning pathogenesis of ovulation-inhibitor-related hypertension, changes (increases) in the renin-angiotensin-aldosterone system are assumed to play a major role (almost all women on the pill exhibit elevated renin-angiotensin-aldosterone activity). Sodium retention may also be determinative. Many clinical and laboratory studies have demonstrated that it is the estrogen content of ovulation inhibitors that is responsible for the increased plasma renin activity. The study recommends: 1) women who wish oral contraceptive therapy should give careful family and personal histories and be tested for blood pressure before and during treatment (monthly, then after 6 months twice yearly); 2) careful supervision is indicated for women with high blood pressure or other cardiovascular disorders in their history, present or former kidney disorders, arterial hypertension, pregnancy toxemias, adipositas, or diabetes mellitus; 3) abnormal weight gain may be an early symptom; 4) if any rise in blood pressure is observed, ovulation inhibitor medication should be discontinued immediately; and 5) ovulation inhibitor-induced hypertension should be considered in differential diagnosis in young women with arterial hypertension.
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PMID:[Oral contraceptives and arterial hypertension]. 437 45

3 cases of women becoming hypertensive while taking oral contraceptives are presented. The first was a 35-year-old mother of 4 who had developed hypertensive kidney disease in her last pregnancy. Before contraception her blood pressure was 130/75; it rose to 140/80 in 3 months and 160/100 in 6 months after taking Ovariostat (2.5-mg lynestrenol and .075-mg mestranol, combined). 2 months after discontinuing usage her pressure was 140/80. The second was a 45-year-old mother of 2 whose pressure climbed from 120/70 to 180/120 within 3 months of starting Planor (2-mg norgestrienone and .05-mg ethinyl estradiol, combined), and fell to 130/80 3 weeks after discontinuing usage. The third was a 32-year-old woman with blood pressure of 120/70 before taking Ovaristat. Within 15 days her pressure was 170/90, accompanied by severe headaches. 1 month after discontinuing usage it returned to 120/70. The discussants mention several cases in their experience, and agree with the authors that women with hypertension in pregnancy, obesity, or diabetes should not be given the pill. Normal patients should be followed carefully and advised to keep a low salt diet and normal weight.
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PMID:[Arterial hypertension during treatment with estro-progestative drugs]. 515 54

A 43-year-old man suddenly experienced severe headaches and involuntary flexion-extension movements of four limbs, which were followed by hypertonic extension of the limbs lasting for a few hours. Two days later, he experienced generalized tonic seizure without loss of consciousness. After the seizures, he remained hemiparetic on the right side. His past medical history was non-remarkable, and the histories of hypertension, diabetes mellitus, head trauma and significant infectious diseases were all denied. Cerebral angiography performed 22 days after the onset showed a segmental, irregular narrowing of the left A2 segment and an aneurysmal outpouching immediately proximal to the stenosis. CT scan revealed a low density area in the left frontal lobe, corresponding to the territory of the involved left anterior cerebral artery. Cerebral angiography was repeated twice in the succeeding 6 months. Each time, the involved A2 segment showed persistence of narrowing, but its shape showed definite changes with the passage of time. A diagnosis of dissecting aneurysm of the anterior cerebral artery was reached by the characteristic angiographic features, and the patient was treated conservatively. Dissecting aneurysm of the cerebral arteries have been reported much less frequently than those of the aorta or other extracranial arteries. Recently, however, such reports are increasing in number, seemingly due to enhancement of knowledge of typical angiographic features, such as string sign, rosette sign, pearl reaction, double lumen and several others. Most of intracranial dissecting aneurysms involve the middle cerebral artery or vertebral-basilar artery, and the ones involving solely the anterior cerebral artery as in this present case are very rare.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[Dissecting aneurysm of the anterior cerebral artery: report of a case]. 650 59

Oral contrceptives (OCs), usd by over 30% of reproductive aged women in Belgium, are by far the most widely used contraceptive in that country. The various types of OCs include monophasic, biphasic, and triphasic combinations of an estrogen and a progestin, sequentials containing estrogen only for 7-14 days followed by a progestin through the 21st day; macrodose or microdose progestin only formulations, 3-month injectable progestins, and the morning after pill. Side effects of OCs are mainly due to metabolic effects on coagulation factors, the renin-angiotensin system, glucose tolerance, or the lipid profile. Users of OCs face increased risks of cholelithiases, thrombophlebitis, thromboembolism, cerebrovascular accidents, myocardial infarcts (among smokers over 35 years of age), and hepatic adenomas. The most troubling secondary effect is the excess cardiovascular morbidity and mortality show by contraceptive users, not just those who are obese, hypertensive, or who have histories of vascular pathology, but also those over 40 years of age and smokers. Lenght of use of OCs does not increase vascular risks. Epidemiologic studies demonstrate that vascular risks are reduced in lower dose formulations. Absolute contraindications to OC use include serious cardiovascular problems, severe hepatic pathology, estrogen-dependent tumors, pregnancy and undiagnosed gynecologic problems, and significant hyperlipidemia. Relative contraindications include severe headaches, cholelithiase, previous cholestasis of pregnancy, severe renal disease, fibromyomas, benign breast disease, age over 40 years, smoking, surgery anticipated within 4 weeks, infectious mononucleosis, falciform anemia, and immediate postpartum and lactation. Epilepsy, diabetes, depression, and varicose veins are not strictly speaking contraindications but require additonal surveillance. Lower dose formulations should be prescribed if possible. OC users should be followed up every 6-12 months. Among other steroidal contraceptive methods, sequential OCs and high dose progestin-only formulations are used for short-term treatment of specific conditions. Progestin-only minipills are used when an OC is desired but estrogens are contraindicated. Injectable progestins should be reserved for patients who for cultural or medical reasons can use no other type of contraceptive. Morning-after pills should not be considered a regular form of contraception. If OCs are used in adolescents, a low dose pill is indicated. Low dose OCs may be indicated for diabetics because of the danger of infection with IUDs and the lesser efficacy of barrier methods. If OCs are used in epileptics, they should be regular dosed because of the danger of drug interactions. Only low-dose formulations and progestin-only minipills should be used by women over 40.
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PMID:[The choice of oral contraception in 1984: general indications and specific cases]. 672 93

Patients with signs and symptoms of giant cell arteritis may have normal temporal artery biopsy specimens. To study the relationships between signs and symptoms of this disease and the ultimate clinical diagnosis, we reviewed 51 patients who had undergone temporal artery biopsy. The mean age of the patients with abnormal biopsy specimens was higher than that of patients with normal biopsy specimens. We found headache, fever, and jaw claudication were useful symptoms in predicting abnormal biopsy specimens. The ultimate diagnoses of patients with normal biopsy specimens and no response to treatment showed high incidence of malignant neoplasms and diabetes mellitus.
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PMID:The ultimate diagnoses of patients undergoing temporal artery biopsies. 673 72

With the primary objective of examining the practice of prescribing oral contraceptives (OCs), a questionnaire was sent to 180 general practitioners and 45 community health doctors involved in family planning. 6 case histories were listed and doctors were asked to report their prescribing practice in 36 different hypothetical situations. They could choose 1 of 3 options--to prescribe the combined pill, the progestogen-only pill, or not prescribe OCs. They were also asked about changes in their prescribing practice, the 3 OCs prescribed most often, when a progestogen-only would pill be prescribed in preference to the combined pill, and views on the role of others in prescribing OCs. Completed questionnaries were returned by 124 (69%) general practitioners and 45 (80%) of family planning doctors. All were least likely to prescribe OCs in cases of hypertension or family history of ischemic heart disease. Diabetes and headache were each seen as less of a contraindication, and few doctors saw either age or fibrocystic disease of the breast as increasing the risk. Within each case history, smoking emerged as the most important contraindication. Almost all doctors reported changes in their prescribing practice; these related to enhanced understanding of the risks of OCs and to the availability of newer preparations. The 3 most commonly used OCs were the 30 mcg estrogen preparations (low and high progestogen) and the progestogen-only pill. Nearly all the doctors replied that they would prescribe the progestogen-only pill but not the combined pill in certain circumstances, the most commonly cited being when the woman was over age 35, was breastfeeding, had risk factors for cardiovascular disease, or smoked. The 2 groups of doctors showed different attitudes towards the role of other staff in prescribing OCs. Although 2/3 of the general practitioner group felt that prescribing should be limited to doctors, this view was shared by only 1/4 of the family planning group.
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PMID:Prescribing of oral contraceptives in Oxfordshire. 688 88

Eighteen cases of paralysis of the IIIrd cranial nerve are studied, 9 of which were of ischemic origin (diabetes, hypertension or arteriosclerosis), and 9 secondary to aneurysm of the posterior communicating artery. Seven patients from the first group and all of the second suffered from headaches. This study deals essentially with the associated painful symptom, its localisation, its nature and its value in the differential diagnosis of the two conditions.
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PMID:[Paralysis of the IIIrd cranial nerve. Pain and its value in the differential diagnosis (author's transl)]. 701 64


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