Sheehan syndrome (Simmond syndrome, postpartum hypopituitarism or postpartum pituitary gland necrosis).
Subgect #3.
Neuroendocrinological syndroms in gynaecology.
NEUROENDOCRINE SYNDROMS
Premenstrual syndrome is a complex of symptoms, which appears in a few days before menses and is manifested in vegetative-vascular, endocrine-metabolic and nervously-psychic disorders.
Clinic. For 2-10 days before menses there appears headache, nausea, vomiting, abrupt irritability or depression, tearfulness, tachycardia, stomach-ache, itching of skin, considerable swelling and pain in breasts. With menses beginning these pathological signs decrease and then disappear. Menstrual function is not disturbed.
Treatment. Psychotherapy, autotraining, medical physical training, poli-vitamins, diet, sedatives (preparations of Valerianne, Trioxasin, Elenium, Seduxen). If there is edema diuretics are used.
Postcastration syndrome is a complex of pathological symptoms (nervously-psychic, vegetative-vascular and endocrine-metabolic), which appear after surgical ablation of ovaries. Ovarian ectomy causes exclusion of important link in system "hypothalamus-pituitary-ovaries-uterus" and needs considerable reorganization of all incretion organs, especially adrenals and thyroid. Pathological symptoms' complex, that appears in the process of organism adaptation to sudden lowering of woman's sexual hormones amount, appears in 60-80% of operated patients. The younger woman is the greater of operation volume, the more severe is the disease.
Clinic. First signs of postcastration syndrome appear in 2-3 weeks after the operation. Estrogens deficit causes neurovegetative (heat flows, sweatiness) and psychoemotional disorders (increased irritability, dizziness, sleep disorders). Endocrine-metabolic disorders contribute to development or to progressing of diseases in hormone-dependent organs and cardiac-vascular system (essential hypertension, IHD, dyshormonal cardiopathy). Obesity, osteoporosis, atrophic colpitis, cystalgy, changes in skin — the lowering of its elasticity and alopetia can develop. Atherosclerosis and glaucoma progress. A blood coagulation process is violated.
Treatment. The treatment is held according to the stages. They take into account operation heaviness and presence of concomitant diseases. Cure includes unmedicinal therapy — medical gymnastics, walks, water procedures (shower-bath, herbage baths, cold sower), massage, accupuncture, physiotherapy, and medicinal — hormonal replacement (therapy with sexual hormones in cyclic mode or by combined estrogen-gestagen preparations) therapy. Hormonal therapy is prescribed for patients of reproductive age. From all estrogen preparations the lightest ones are used. They take Estriol daily during the period of 21 day with the following 7-day interruption. Such therapy is indicated at atrophic colpitis, because it removes vagina dryness and decreases painful feelings during intimacy.
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In women of elder age the superiority is given to non-hormonal therapy. For normalization of the central nervous system function Reserpin, Obsidan, Stugeron, vitamins В , B6, E are taken. Small tranquilizers and neuroleptics (Thasepam, Frenolone) at psychoemotional disorders should be used too.
Climacteric syndrome — a complex of symptoms, that complicates a transitional period. Signs of pathological climacterium are observed in 40-60% of women.
Clinic. Most typical signs of pathological climacterium are neurovegetative features: heat "flows" to face, head and upper part of body, those are attended by
redness of face and intensive sweating, palpitation, dizziness. Patients suffer from headache, irritability, decreasing of working capacity, disorders of sleep. Chronic diseases such as hepatocholecystitis, gall-stone disease, ulcerous stomach and duodenum disease, ischemic heart disease, essential hypertension become acute, varicose disease flow becomes worse. Ecessive amount of estrogens from metabolic processes causes increasing of cholesterol level in blood, and lowering of gestagens rate causes increasing of blood coagulability and thrombosis. In patients with atherosclerosis and hypertension in clinic of climacteric disorders prevails a cerebral component — headache, dizziness, worsening of memory, insomnia. More frequently there appear hypertensive crises. Vascular complications and blood effusions are possible.
Climacteric syndrome is developed in patients with vulnerable nervous system in stress situations caused by work or home conflicts. Astheno-neurotic syndrome with hypochondriac fixation of personality with tearfulness, feeling of fear, trouble, depression can also apear. Difficult depression that almost does not respond to treatment is observed in some patients.
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Estrogens and gestagens deficit causes development of methabolism and endocrine violations. Dystrophic changes of vulva, atrophic (sometimes even ulcerous) colpitis, cystalgyas refer to urinary genital symptoms. The tonicity of pelvic floor muscles and urinary bladder sphincters is lost. It can cause incontinence, frequent urination even when small amount of urine in urinary bladder. Decreasing of estrogenic stimulation causes suppression of vaginal epithelium cells ripening and decreasing of glycogen amount in their cytoplasm. That's why a vagina self-clearing process is disturbed, and afterwards it ceases. Non-keeping of personal hygiene rules can cause senile colpitis development. If woman continues sexual life, then dryness of mucous causes microtraumas and unpleasant feelings during intimacy.
"Dry" conjunctivitis and laryngitis those are connected with insufficient secretory ability of mucous membranes belong to extragenital Estrogen deficiency states. On face there can appear separate wiry hair, sometimes voice timbre becomes lower. It is explained by reinforced synthesis of androgens in ovaries and adrenals. In postmenopausal period osteoporosis develops. It is caused by Calcium and Phosphorus loss. 2/3 of patients with climacteric syndrome suffer from lipid metabolism disorders of different degree.
Treatment The first stage of cure is unmedicinal therapy, the second one is medicinal non-hormonal therapy, the third one is hormonal therapy. At severe forms of climacteric syndrome simultaneously are used all of the three types of treatment.
It is of particular importance to convince woman in necessity to lead the healthy way of life, proper feeding, to keep the work and rest regimen. Morning gymnastics according to age, walk, adequate physical loading are also obligatory.
In domestic conditions they take hydrotherapy — contrasting shower-bath (alternation of cold and hot water is a peculiar vessels massage and prevents progressing of vegetative-vascular manifestations), hot baths for feet, before sleep they have sedative general baths of moderate temperature with addition of medical plants. If possible, they are recommended a health-resort cure, in usual for woman climatic zone. Physiotherapy — neck and face galvanization is also effective. Novocain electrophoresis on collar zone is taken. Procedures should be accomplished with massage of jugular-humeral allotment.
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Sedative therapy — Phrenolone, Ethaperasine,Triphtasin, beginning from minimum doses 0,5-1 mg per day, gradually increasing it to reaching constant effect without appearance of weakness, somnolence, that testifies about preparation overdosing.
Such variants of hormone therapy are possible:
with Androgens — for patients with proliferative processes in genitals, associated with hyperestrogeny (uterine fibromyoma, mastopathy, osteoporosis). Androgens are contra-indicated at virile syndrome, stabile hypertony
synthetic progestines in cyclic mode
with combination of estrogens and androgens. Synergic effect of these hormones on diencephal region and antagonistic effect on genitals is base of this method. Androgens decrease proliferative action of estrogens, and estrogens decrease the virilizing androgen action
with combination of estrogens and gestagens — imitation of menstrual cycle: in the first half they should take estrogens, in the second one — progesterone
Long using of estrogens is undesirable due to danger of hyperplastic processes development (estrogens stimulate endometrium, myometrium and also breasts' tissues proliferation). Estrogen hormones are not considered to be cance-rogens, they don't cause development of cancer. But if a tumor transformation of genome has already take place in tissue, high content of estrogens hastens tumor growth.
Patients with climacteric syndrome use preparations, those decrease clinical manifestations or remove them completely, improve health state, and some of them at the same time are a prophylaxis of malignant diseases of genitalia. Following medecines are recommended: Progynova-21 — 1 dragee per day during 2-6 months, Cyclo-Progynova — 2-phase preparation, that is used from the 5th day of menstrual cycle till the 26th day, further a 7-day interruption. This medicine is not a contraceptive, that's why, if menses does not come, it is necessary to make a test on pregnancy. Climen, Climonorm, Climactoplan, Ovestin, Livial, Divina, Divitren, Trisequense are effective. Besides of tabulated forms there are offered to use transdermal gel Divigel, Extraderm and preparation of prolonged action Gynodiane-depot 1 ml of oily solution i/m once on 30 days.
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Prescribing of that or other scheme of hormonal therapy is admissible only after careful examinaton of a patient. Tests of ovaries' functional state diagnostics before cure and in its dynamics should be taking into account.
The virile syndrome. Is characterized by development of secondary masculine sexual signs in women. Disease can develop in any age.
Basic manifestations:
masculine body building — skeleton, muscular system
atrophy of breasts
hypertrophy of the clitoris
hairity growing according to masculine type (hypertrichosis, hirsutism)
irregular menstrual cycle at first there appears hypomenstraal syndrome (oligo-, hypo- and opsomenorrhoea), then — stabile amenorrhea
Causes of virile syndrome are cortex hyperplasy of adrenal glands (virile syndrome of adrenal origin); tumors of adrenal glands' cortex (virile syndrome of tumular genesis); syndrome of sclerocystic ovaries (virile syndrome of ovarian origin), that is followed by enlarging and cystic changes of ovaries, irregular menstrual cycle, infertility and hirsutism; masculinizing ovaries' tumor — adrenoblastoma.
Diagnostics is complicated. Except of the obligatory methods of gynecological examination it must include the estimation of patient's hormonal status with 17-cetocteroids determination; tests with Corticotropin, Dexamethazon, Prednisolon; ovaries and kidneys' sonography; computer axial tomography for tumor diagnostics. For specification of diagnosis laparoscopy with biopsy of ovaries should be performed.
Treatment is etiopathogenetic. Depending on the disease cause it is operative (tumor ablation, ovary resection) or conservative (hormonal therapy).
Polycystic ovarian syndrome (PCOS) affects 4% to 12% of women of reproductive age. Despite being heterogeneous in nature, the hallmarks of the disease are hyperandrogenism and chronic anovulation. Since its description in 1935 by Stein and Leventhal, much has been learned about the pathophysiology of PCOS from its neuroendocrine underpinnings to an ever-growing understanding of the link between obesity, insulin resistance (IR) and PCOS. Common symptoms of PCOS include the following:
· Menstrual disorders: PCOS mostly produces oligomenorrhea (few menstrual periods) or amenorrhea (no menstrual periods), but other types of menstrual disorders may also occur.
· Infertility:This generally results directly from chronic anovulation — High levels of masculinizing hormones: The most common signs are acne and hirsutism (male pattern of hair growth), but it may produce hypermenorrhea (heavy and prolonged menstrual periods), androgenic alopecia (increase hair thinning or diffuse hair loss), or other symptoms.
· Metabolic syndrome:This appears as a tendency towards central obesity and other symptoms associated with insulin resistance .
Anatomy of the normal and polycystic ovary 1990 NIH diagnostic criteria include both 1 and 2 – chronic anovulation, clinical and/or biochemical hyperandrogenism. 2003 Rotterdam diagnostic criteria (two out of three): oligo- or anovulation, clinical and/or biochemical hyperandrogenism, polycystic ovaries.
The treatment includes lowering of insulin resistance levels (in case of excessive body weight – weight loss) , restoration of fertility, treatment of hirsutism or acne , restoration of regular menstruation, and prevention of endometrial hyperplasia and endometrial cancer.
Sheehan syndrome (Simmond syndrome, postpartum hypopituitarism or postpartum pituitary gland necrosis).
It is a rare complication of pregnancy, usually occurring after excessive blood loss. Due to the blood loss and hypovolemic shock during and after birth the ischemic necrosis of the pituitary gland may occur, resulting hypopituitarism – decreased function of all the pituitary hormones. The symptoms include: agalactorrhea, amenorrhea or oligomenorrhea, hypopituitarism (tiredness, intolerance to cold , constipation, weight gain , hair loss, slowed thinking, a slowed heart rate, low blood pressure), secondary adrenal insufficiency(fatigue, weight loss, hypoglycemia, anemia).
The treatment includes the hormonal replacement therapy with all the hormones of the pituitary gland.
Hyperprolactinaemia or hyperprolactinemia (HP, Chiari – Frommel syndrome). The causes are: the Hypothalamic nuclei lesion due to rheumatism, systemic autoimmune diseases, severe infections, focal poor blood circulation of the hypothalamic area, pituitary tumors, causing excessive release of certain hormones or compression of the hypothalamic nuclei, postpartum period on the background of long-term breastfeeding. Scientists have observed that the Chiari –Frommel syndrome predominantly occurs in women with a history of childbirth.
The symptoms include: Symptoms of neurogenic character (headaches, visual disturbances, sweating, hot flashes, sleep disturbances, emotional lability, irritability), the increase of both mammary glands (it is possible to palpate enlarged lobules), galactorrhea ( the discharge of milk from the breast that is not associated 44 with breast-feeding, maybe both moderate and abundant), the absence of menstrual function and menstruation, obesity of different degree or, conversely, lack of body weight, hirsutism - excessive hair growth, reduced pigmentation areola area of the nipple, atrophic changes in the mucous membranes and the entire structure of the external genitalia, infertility.
The investigations should include: X-ray examination or any kind of tomography of the skull (the focus is on the area of sella, where the pituitary gland and the hypothalamus is located), ultrasound examination of pelvic organs and breasts, cytological and histological examination of vaginal and uterine smears, Blood analysis for levels of sex hormones (FSH, LH, prolactin-releasing hormone, estrogen, progesterone), urine for the of sex hormones and their metabolites.
Treatment: In case the cause is the pituitary tumor the surgical treatment is needed, if the disease appeared in the classic version and is associated with the destruction of the primary nuclei of the hypothalamus, such patients are subject of conservative medical correction by hormones. For the treatment of infertility special measures are not required because, in case the hyperprolactinemia is treated the ability to fertilize is restored.
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