Hello everyone & fibroids question

March 18, 2005

Hi, everybody:

I know this is slightly off topic but I am a Hashi's patient who is

on Armour and also on progesterone cream. I posted this on another

forum and didn't get one answer. I know there's some common sense

out there and if anybody is willing to give me their thoughts on

this, I'd sure appreciate it!

" For some of you that don't know my history, I was diagnosed with

lots of fibroids a couple months ago and have already had 2 lap.

surgeries for pelvic pain and now face a third surgery. My doctor

insists that fibroid tumors cannot cause pain but I've had lower

back pain since December and a sharp pain at the top of my right leg

for about 6 weeks. My last ultrasound indicates an enlarged,

irregular, inhomogenous uterus and several fibroids, some embedded

in the wall of the uterus. My question: if everything is enlarged

and inflamed, isn't it possible that a fibroid or my uterus is

pushing on a nerve or two? I want to ask people with common sense --

I know there is an abundance of it here, and often lacking in the

medical community! "

Thank you!

)

March 18, 2005

Thank you Nat,

I'm only on my 3rd month of progesterone cream. I've had symptoms of

estrogen dominance for AGES, and then I read Dr. Lee's wonderful

book. This doc only discovered these fibroids in late January. She

said I could have a 3rd surgery (oh joy) to have them removed, a

myomectomy, or I could wait and come back in 6 months and have

another ultrasound. I'm debating this all in my head, 'cause I've

read prog. can shrink fibroids, but I'm sick of the pain. I just

think she's crazy for saying there's no way they could cause pain!

> >

> > Hi, everybody:

> >

> > I know this is slightly off topic but I am a Hashi's patient who

> is

> > on Armour and also on progesterone cream. I posted this on

> another

> > forum and didn't get one answer. I know there's some common

sense

> > out there and if anybody is willing to give me their thoughts on

> > this, I'd sure appreciate it!

> >

> > " For some of you that don't know my history, I was diagnosed with

> > lots of fibroids a couple months ago and have already had 2 lap.

> > surgeries for pelvic pain and now face a third surgery. My doctor

> > insists that fibroid tumors cannot cause pain but I've had lower

> > back pain since December and a sharp pain at the top of my right

> leg

> > for about 6 weeks. My last ultrasound indicates an enlarged,

> > irregular, inhomogenous uterus and several fibroids, some embedded

> > in the wall of the uterus. My question: if everything is enlarged

> > and inflamed, isn't it possible that a fibroid or my uterus is

> > pushing on a nerve or two? I want to ask people with common

sense -

> -

> > I know there is an abundance of it here, and often lacking in the

> > medical community! "

> >

> > Thank you!

> > )

March 18, 2005

Since my story is kind of gross, hope you don't mind if I send it to

yu personally. Gosh are doctors stupid or what. Sure fibroids can

cause pain. I was on fibroid newsgroups for about 3 years and there

was pain all over the place. First off they stretch and distort the

uterus and pull the ligaments that hold the uterus and other organs

in place. Then, if you've had two Laps, you might have some

adhesions. They can definitely cause pain. Then, fibroids sometimes

die and this will cause severe pain. (See Stanley West's " The

Hysterectomy Hoax. " He talks about that.)

I had them for over 6 years and they got huge, 20 week pregnancy. I

had them all removed with mymectomy. But, because I was still an

undiagnosed hypo, I grew two more small ones. Hypothyroidism causes

the uterus to be highly sensitive to estrogen and causes high

estrogen levels. Adrenal problems related to hypothyroidism seem to

increase estrogen sensitivity in tissues. hypothyroidism also lowers

immune function so you don't make natural killer cells that attack

tumors. But, since I have been on 3-3/4 grains of Armour, they have

stoped growing. I've had these for about 3 years. They can be quite

uncomfortable depending on where they are located and their size. My

big ones put pressure on my bowel and that was what drove me to

surgery. I felt uncomfortable pressure and eventually they

interfered with my bowel function and I was spending large amounts

of time in the bathroom. One time back then, I developed a severe

pain from one on the right side. I could hardly walk for two weeks.

It was probably one that died. They are known to outgrow their blood

supply and then they die and are reabsorbed.

There is a lot of debate about progesterone cream and fibroids. The

drug RU486 is being studied to shrink fibroids. It works by dropping

progesterone levels to almost nothing. RU486 also raises natural

killer cell levels and DHEA levels. I used progesterone cream for

about two years while I had fibroids and It did not slow them down.

I could not verify if it made them grow faster or not. It made me

feel better, but the fibroids kept growing. The jury is really still

out on progesterone. Dr. Lee says it will get rid of them, but I

have not seen any reports of this happening on the newsgroups I was

on. Some people think Uterine Fibroid Embolization is great, but

while I was on the newsgroups, there was a disturbing number of

reports starting to come in that this proceedure did not last and

they would start to grow again. Then people were forced into

myomectomies. But, the UFE proceedure left a lot of adhesions that

made myomectomy difficult sometimes.

In my book if you feel pain, then you have pain. Doesn't matter what

doctors think. I ended up flying to Boston for surgery with a great

doctor, Dr. Levine. Because mine were so big, hardly any

regular doctor could do a myomectomy. Dr. Levine uses bloodless

surgery and I did not need a blood transfusion for my surgery. But,

I can't help but think that if I had had sufficient thyroid, I wuld

have never needed surgery. Fibroids are very rare in well treated

thyroid patients.

Tish

____________________

Here are some sources related to fibroids and hypothyroidism.

_______________________

" Thyroid, Guardian of Health " by Philip G. Young, MD, Trafford

Publishing, , BC., Canada, 2002

But menstrual irregulaities are not the only hrmful affect low

thryoid has on the uterus. A lack of thyroid greatly enhances the

growth of uterine fibroids as well. If a woman is on sufficient

amounts of thyroid the further growth of uterine fibroids usually

will be blocked and frequently they will start shrinking. Besides

uncontrolled bleeding, the major reason that women have

hysterectomies is symptomatic uterine fibroids which can cause

discomfort and contribute to excessive bleeding. Hypothyroidism also

increases the incidence of uterine cancer which is the reason behind

most the remaining hysterectomies. So thyroid has an almost magical

impact on many of the woes associated with womanhood; it takes them

away. (Page 117)

And as mentioned elsewhere, there is a close relationship between

the binding sites of thyroid and the binding sites of estrogen, so

the function of thyroid and estrogen are intertwined in subtle ways.

(Page 116)

__________________________

" Hypothyroidism: The Unsuspected Illness " by Broda O. , M.D.

and Lawrence Galton, Harper & Row, Publishers, New York, 1976

Fibroid tumors have been rare in hypothyroid women who have been

maintained on adequate thyroid therapy. It is possible to produce

fibroids in experimental animals by injection of estrogens, and

there is evidence of excess of estrogens in hypothyroid women. In

hypothyroidism, there is increased activity of the pituitary gland

aimed at trying to stimulate the thyroid to produce more hormone

secretions, and the increased pituitary activity may spill over to

affect ovaries and increase their estrogen output. (Page 133)

________________

[Diagnosis of thyroid function in uterine myomatosis]

[schilddrusenfunktionsdiagnostik bei Myomatosis uteri.]

Zentralbl Gynakol 1989;111(1):47-52 (ISSN: 0044-4197)

Lange R; Meinen K Gynakologisch-Geburtshilflichen Abteilung, St.

Lukas Klinik Solingen.

A correlation between thyroid disease and uterine myoma has been

discussed till the fourth decade of this century. Since then, this

possible connection was given no further notice. We examined 79

women needing a hysterectomy for various reasons regarding

myometrial histology, thyroid function and thyroid antibodies. The

patient group bearing myomas showed significantly more frequent

(23%) pathological TRH/TSH stimulation tests results than the

control group (3.7%, p = 0.0543). 10 of 22 patients with myomas had

microsomal and/or thyroglobin antibodies, compared with none in the

control group (n = 17, p = 0.0019). Therefore regarding these

results a connection between thyroid disease and uterine myoma

should undergo a more detailed examination.

______________________________

" The Great Thyroid Scandal and How to Survive It " by Dr. Barry

Durrant-Peatfield MB BS LRCP MRCS, Barons Down Publishing, London,

2002,

Part B - Oestrogen, Progesterone & Testosterone

The hormones that keep us male and female are crucially affected by

thyroid and adrenal function; and in turn can effect the proper

functioning of the thyroid itself. So let us see where they fit in.

Since my approach to metabolic problems is holistic, we have to ask

if thyroid and adrenal insufficiency may be altered or worsened by

deficiencies elsewhere. The answer is of course, yes. Since a state

of lowered metabolism means that nothing really works as it was

designed to, it follows that other hormone producing glands may not

do their job properly either. It is a bit like an extraordinarily

complex piece of electrical machinery, designed for 240 volts,

running on 210 volts. It runs, but the lights look a bit dim and

flicker a bit. Bringing up the voltage - gently - will get

everything working again.

So far as other components of the endocrine system go, we must be

prepared for partial recovery only, and supplementation may well be

indicated elsewhere as well. We are talking mostly about sex

hormones here, and the effects of the menopause on both sexes. We

have learnt already how important the adrenal corticosteroids are in

the maintenance of the body's normal health; the male and female sex

hormones, which are of course also steroids, are just as

extraordinarily important in their own right. (It may have perhaps

surprised you to realize that the whole body, most especially many

of its hormones, is based on the steroid molecule. The use of the

word " steroid " has been denigrated in the popular mind as being

potentially, if not actually, dangerous, and this is a complete

distortion. The contraceptive pill, for which millions of

prescriptions are written weekly, is based on two steroids and few

doctors and few patients are especially concerned that they do in

fact belong to the great family of steroids).

We will start with the female menopause, which will be hastened or

worsened by a low thyroid/adrenal state. Literally, the menopause

means " the last period " . For some women this is an abrupt thing,

there one month and gone the next. Very often the process is rather

more protracted than this; the periods start lengthening and sputter

about; they may become heavy with pain and floods, or become very

light and irregular. And menstrual problems, with heavy irregular

periods, are certainly associated with low thyroid.

So we need to have a look at the whole business, so that we can

decide to intervene if necessary while treating the metabolic

problems. Women actually produce three different sex hormones,

oestrogen (which has three different forms: oestradiol, oestrone and

oestriol), progesterone and testosterone. You thought testosterone

was a male hormone, didn't you. Well, it is; but women produce it

too - though less than men of course. (The reverse is also the

case.) In general oestradiol, the main oestrogen, comes from the

ovaries, the other two from the adrenals, directly or indirectly,

and more after the menopause. The way it all works is this. As the

menarche (the start of periods) approaches, the ovaries start to

produce oestrogen and under the influence of a pituitary hormone,

the Follicle Stimulating Hormone (FSH), an ovarian follicle (of

which there are many hundreds containing egg cells waiting their

time) matures an ovum which surfaces about mid cycle and is

released. It finds its way into one of the fallopian tubes (right or

left, depending on which ovary produced the ovum) where it may or

may not be fertilized. The place from where it was released on the

ovary undergoes a change to produce the Corpus Luteum or " Yellow

Body " . This structure begins to produce under the influence of

Luteinizing Hormone (LH) from the pituitary, another hormone,

progesterone. This prepares the lining of the womb for implantation

if the ovum is fertilized. Oestrogen and progesterone are produced

together for the second half of the cycle; and then the supply is

cut off abruptly which starts off the menstrual period.

Hypothyroidism can affect this process in several ways. To start

with, a low thyroid state affects the onset of the first period,

oddly enough in two opposing ways. The first period may come

unusually early at 8, 9 or 10 years old; or, it may come unusually

late, 15, 16 or 17 years old. Periods starting abnormally like this

should raise a suspicion about the thyroid at once.

The periods may be abnormal in other ways. They may be exceedingly

painful with collapse and prostration of the unfortunate girl; they

may be very heavy or very light or come at irregular times. There

may be premenstrual tension to make life miserable. These problems

may occur at any time of life, but may sort themselves out a bit

after having children. Then in the later thirties and early forties

it all goes wrong and flooding and terrible PMT may ruin things so

badly that relationships suffer. The gynecologist may not think of

thyroid dysfunction as a cause and the ladies then become the target

of various synthetic hormone combinations, which may or may not

bring relief. It is at this point, of course, that hysterectomy

becomes the treatment choice, and worn out with it all, the unhappy

sufferer consents to surgery. Relief from the terrible periods may

well justify the hysterectomy for the patient; but it may have

missed the point altogether. As I said earlier, hysterectomy is very

likely to affect thyroid activity. There seems to be a chemical

dialogue between the womb and the thyroid; and interference -

including sterilization, termination, or even a D&C, seems to damage

thyroid function for many.

The weight gain, which nearly always occurs, is not due to comfort

eating while grieving for one's lost fertility, but because thyroid

activity may be further damaged. This, and the other symptoms of a

running down of thyroid activity, is a heavy price to pay for an

operation for which one out of every three, at least, wasn't

necessary and could have been avoided if thyroid status had been

properly assessed and treated.

The other worry which besets women at this time of their lives is

premenstrual tension (PMT) or as the Americans call it (PMS)

premenstrual syndrome. Some doctors won't have that this occurs at

all. I remember reading an authoritative article by a lady doctor

who discounted it completely; one just wonders what planet she came

from. Not only is it a very real problem; if anything it is getting

worse. Although a number of causes have been cited, it seems clear

that it is associated with an imbalance between the oestrogen and

progesterone production. This last, may drop anyway with the general

loss of viability of the ovum and the corpus luteum; but it is much

worse with deficient thyroid hormone. Throughout my experience with

low thyroid, I have been staggered to find that some women lose

their PMT within a month or so of starting their thyroid

supplementation - simply the result of improved progesterone

production. Where progesterone production in the mid thirties and

forties has not been improved by thyroid supplementation, very

thoughtful consideration must be given to the provision of

progesterone supplementation. The standard way of doing this is by

the use of a group of artificial progesterones, which are called

progestogens and the synthetic hormone Norithesterone is an example.

While these may well be helpful for some women, they have a number

of side effects which have made them less and less popular;

nevertheless, an alternative must be sought. As oestrogen dominance

brings with it its own problems of bloating, weight gain and

increased risk of cancer, a progesterone supplementation is

essential. Of increasing popularity nowadays is the use of natural

progesterone, which is actually extracted from plants and is

incorporated in creams which may be simply rubbed into the skin

daily. Although establishment thinking is, as might be expected,

somewhat suspicious of the natural product, favoring the artificial,

very many thousands of women are greatly benefiting from transdermal

progesterone (see Appendix D).

Another worrying result of a reduction in thyroid function is a

reduction of red blood cell production; many people are troubled by

a refractory anaemia (when it is unresponsive to treatment), which

adds to their general lack of well-being and exhaustion. How much

worse is it then, when heavy prolonged periods are added to the

problem.. . Iron, folic acid and vitamin C would seem to be

essential, especially in the early phases of treatment. A most

alarming gap in the management of infertility, is the failure to

realize that a prime and a gravely neglected cause is

hypothyroidism. It is obvious that there are several ways the

healthy ovum can be affected: its production, its maturation, proper

fertilization and implantation....... (Pages 135 - 139)

___________________________

Ginecol Obstet Mex. 1969 Dec;26(158):777-85.

[Report on the relation between limited hypothyroidism and uterine

fibromyomatosis]

[Article in Spanish]

Gutierrez JT.

PMID: 5408031 [PubMed - indexed for MEDLINE (Paper can be purchased

from PubMed)

_____________________

Akush Ginekol (Mosk). 1988 May;(5):46-50.

[The reproductive system of patients with disordered thyroid

function]

[Article in Russian]

Sosnova EA.

PMID: 3177773 [PubMed - indexed for MEDLINE] (Paper can be purchased

from PubMed)

___________________________

J Assoc Physicians India. 1993 Feb;41(2):88-90.

Comment in: J Assoc Physicians India. 1993 Nov;41(11):761-2.

Hypothyroidism presenting with polycystic ovary syndrome.

Sridhar GR, Nagamani G.

Endocrine & Diabetes Centre, Visakhapatnam.

During a 30 months period, two women of primary hypothyroidism

(2/13; 1.04%) presented with features of polycystic ovary syndrome

(PCOS). In hypothyroidism, sex hormone binding globulin levels are

decreased; increased conversion of androstenedione to testosterone,

and aromatization to estradiol are present, all these being an

exaggeration of biochemical changes characteristic of PCOS. Besides,

metabolic clearance rates of androstenedione and estrone, the

putative mediators of PCOS, are reduced. Hypothyroidism can either

initiate, maintain or worsen the syndrome. Correction of

hypothyroidism when present, would therefore form an important

aspect in the management of infertility associated with PCOS.

Publication Types: Case Reports

PMID: 8053991 [PubMed - indexed for MEDLINE]

__________________

Pediatr Akus Ginekol. 1968 Sep-Oct;5:55-8.

[Function of thyroid gland in uterine fibromyoma]

[Article in Ukrainian]

Sol's'kii IaP, Chizhova PS, Ivaniuta PI.

PMID: 5743398 [PubMed - indexed for MEDLINE] (Paper can be purchased

from PubMed)

_______________________

Akush Ginekol (Mosk). 1970 Oct;46(10):24-7.

[Functional status of the thyroid gland in patients with uterine

myoma]

[Article in Russian]

Vasilevskaia LN, Kotliarov EV.

PMID: 5519731 [PubMed - indexed for MEDLINE] (Paper can be purchased

from PubMed)

_________________

Ginecol Obstet Mex. 1974 Jun;35(212):657-80.

[Edocrinal study of uterine fibromyoma]

[Article in Spanish]

Nava y R.

PMID: 4138171 [PubMed - indexed for MEDLINE] (Paper can be purchased

from PubMed)

____________________

Akush Ginekol (Mosk). 1967 Oct;43(9):17-21.

[Adrenal cortex and thyroid gland function in patients with myoma of

uterus]

[Article in Russian]

Slepov MI, Novouspenskaia IE.

PMID: 5607969 [PubMed - indexed for MEDLINE] (Paper can be purchased

from PubMed)

________________

Author: GRIFF T. ROSS, M.D.,

Date Published: 01-Jan-1958

Publication: Journal of Clinical Endocrinology and Metabolism 18:

492-500, 1958

Title: SEVERE UTERINE BLEEDING AND DEGENERATIVE SKELETAL-MUSCLE

CHANGES IN UNRECOGNIZED MYXEDEMA

Category: reproductive

Keywords: reproductive, problem, ROSS, SEVERE, UTERINE, BLEED,

DEGENERATIVE, SKELETAL, MUSCLE, CHANGE, UNRECOGNIZED, MYXEDEMA,

treat, women, menstruation, severe, anemia, normal, desiccated,

thyroid

Text: p 492

ABSTRACT

Two cases of severe uterine bleedng associated with unrecognized

myxedema (hypothyroidism) are reported. Degenerative changes in

skeletal muscles were suggested by the results of electromyographic

studies and demonstrated by biopsy of a muscle prior to treatment in

one patient. The uterine bleeding stopped promptly and a normal

menstrual cycle was re-established in both patients after treatment

with desiccated thyroid.

DISTURBANCES in thyroidal function in premenopausal women are often

associated with abnormalities of menstruation. Either menorrhagia or

amenorrhea may develop in patients with spontaneous or postoperative

myxedema. However, when amenorrhea occurs in a premenopausal women

with the secondary hypothyroidism the diagnosis of hypopituitarism

should be considered and excluded. In his book, Means

stated: " Menorrhagia may be sufficiently impressive in ordinary

myxedema so that in several cases that have come to our attention

patients have actually had a dilation and curettage for it when all

they needed was desiccated thyroid for treatment. "

We are reporting 2 cases of profuse uterine bleeding with severe

anemia secondary to unrecognised primary myxedema, in which prompt

cessation of uterine bleeding and restoration of normal menstrual

cycles followed the oral administration of desiccated thyroid.

Significant degenerative changes in the skeletal muscles were

suggested by the results of electromyography and were demonstrated

by muscle biopsy prior to treatment in one of these patients.

p 494

..

....COMMENT

Both these patients were referred for consideration of surgical

treatment for intractable profuse uterine bleeding. Severe

menorrhagia lasting from

p495

six to ten days had been present during the six months preceding the

admission of the first patient to the hospital. After the clinical

recognition of myxedema, it was realized that the bleeding might be

due to the hypothyroidism. For this reason, operation was deferred

until the patient could be restored to euthyroid state. After five

days of oral treatment with desiccated thyroid, the uterine bleeding

ceased. The menstrual pattern subsequently returned to normal with

regard to periodicity and flow.

Despite the fact that the second patient had noted intermenstrual

spotting for many years, the myxedema in all probability began after

her last pregnancy in 1950. There was nothing to suggest anterior-

pituitary insufficiency, since the patient lactated and cyclic

menstrual periods were re-established following parturition. She was

extremely exsanguinated on admission, as shown by the clinical

picture of mild shock and severe anemia. Her response toe desiccated

thyroid was most gratifying, since the uterine bleeding stopped

after seven days of therapy. A checkup after three months off

treatment revealed that she was clinically euthyroid. A remarkable

change had taken place in the facies (Fig. 1). normal menses had

returned.

__________________

Author: JENNINGS C. LITZENBERG, M.D.

Date Published: 01-Jan-1937

Publication: JAMA, 109:1871-1873, 1937

Title: THE ENDOCRINES IN RELATION TO STERILITY AND ABORTION

Category: reproductive

Keywords: reproductive, problem, LITZENBERG, ENDOCRINE, RELATION,

STERILITY, ABORTION, fertile, pregnancy, develop, hormone, fetus,

basal, metabolic, rate, menstrual, thyroid, women, normal

Text: p1871

The endocrines govern the physiology of reproduction from beginning

to end; spermatogenesis, ovogenesis, maturation of the ovum,

ovulation, fertilization, preparation of the endometrium for

nidation, implantation of the fertilized ovum, placentation,

maintenance of pregnancy, development of the fetus, birth and

lactation - all are dependent on hormones initiated and controlled

by the anterior hypophysis.

p1872

.....THE THYROID AND STERILITY

Since 1922 I have studied the relation of the basal metabolic rate

to sterility, abortions, and menstrual disturbances. In our first

small series of sixty-nine consecutive sterile women, in whom no

other evidence of myxedema was present, 50 per cent had a low basal

rate; adding those who had conceived but aborted the figure was 56

per cent. Carefully supervised thyroid medication resulted in 33.3

per cent conception, 14 per cent of whom aborted. One woman

conceived three times under thyroid medication, bringing the

percentage of conceptions to 40. In another group of 114 women, 45

per cent of the married women were sterile and 40 per cent of the

entire group had functional disturbances of menstruation. In a

second series of 137 women, approximately the same figures were

obtained, but in addition we found that 63 per cent had abnormal

menses (our patients all came from a goiter area).

Our third series (including the pervious reports) consists of 255

married women, 49.7 per cent of whom were sterile. Of 332 women,

married and unmarried, 33.5 per cent had functional disturbances of

menstruation. During the fifteen years of our experience to date

(including cases not previously reported) there was a consistent

rate of conceptions of 30 per cent in women with low basal rates.

Haines and Mussey of the Mayo Clinic confirmed our thyroid treatment

of functional menstrual disturbances, saying: " Because of a desire

to determine the effectiveness of thyroid medication alone, in the

treatment of certain menstrual disturbances, no patient received any

other treatment. All were definitely improved; amenorrhea, 72 per

cent; oligomenorrhea, 55 per cent; menorrhagia, 73 per cent, and

general health, 75 per cent. "

Also in this connection Haskins says: " Most gynecologists agree that

thus far, of all the gland products, thyroid has proved to be the

most useful for a variety of endocrine disturbances, including

amenorrhea, oligomenorrhea, menorrhagia, sterility and abortion. "

Marine, long ago (1917) when there was scarcely any usable knowledge

of the endocrines, declared: " The relation of the thyroid to the sex

organs in the female is the most frequent and classical illustration

of the interrelation of the function of glands with internal

secretions. "

adds testimony by saying " The sole endocrine preparation that

has proved itself of real value has been thyroid extract, which is

of use in patients with lowered basal metabolism. "

Novak declared that thyroid medication in sterility and abortion are

more often efficacious than any other form of organotherapy.

Desiccated thyroid was the first, and is still one of the few

successful, substitutional hormone preparations. Perhaps when one

gives desiccated thyroid one is doing to the ovaries what the

pituitary has failed to do through stimulation of the thyroid gland

by means of the thyrotropic hormone.

I quote the concluding paragraph of an editorial in THE JOURNAL:

These reflections [criticisms of the misuse of sex gland hormones]

are not intended to inhibit chemical and biologic studies in

accredited laboratories. Neither do they apply to the carefully

controlled clinical application of accepted knowledge by competent

observers; this is necessary. Rather are they intended (1) to

emphasize that there is a great discrepancy between laboratory

knowledge of the hormones and their clinical application, (2) to

suggest that for the present only those clinicians with facilities

for critical study be encouraged to administer the newer endocrine

preparations to patients and that these clinicians be urged to

publish their negative as well as their positive results, and (3) to

suggest that a large group of physicians not represented in either

of the groups mentioned cease their undiscriminating injection of

unknown substances into unsuspecting patients.

Physicians are perhaps cynical because of our limited knowledge of

the endocrines and the complexity that faces it, but the tendency is

to optimism when it contemplates the accomplishments of the recent

past with their great promise for the future.

_____________________

Author: RUTH C. FOSTER

Date Published: 01-Jan-1939

Publication: ENDOCRINOLOGY 24:383,1939

Title: THYROID IN THE TREATMENT OF MENSTRUAL IRREGULARITIES

Category: reproductive

Keywords: reproductive, problem, FOSTER, THYROID, TREAT, MENSTRUAL,

IRREGULAR, women, period, basal, metabolic, pelvis, metrorrhagia,

amenorrhea, bleed, relief, continue, normal, desiccated

Text: p383

DURING THE PAST few years we have been impressed by the efficacy of

thyroid medication in the treatment of menstrual irregularities.

Because our series of cases has shown results similar to those

reported by clinicians working elsewhere, it has seemed worth while

to summarize our data and present it in confirmation of material

published previously.

Fifty cases treated with thyroid have been observed for a period of

from one to four years. These patients have been seen at least twice

a month. Their ages have ranged from 16 to 34, although 41 of the

series have been under 22 years of age. All have had complete

physical examinations, pelvic studies, and repeated basal metabolic

determinations. With a few exceptions, which will be discussed

later, only those who showed no pathology in the pelvis have been

treated with thyroid.

.....Among this group of patients 25 complained of dysmenorrhea which

was of sufficient severity to cause repeated absence from classes.

Seventeen complained of scanty or delayed menstrual periods with

intervals of as long as three months. Thirteen complained of too

frequent periods or of inter-menstrual bleeding, while 7 had

excessive flow together with the metrorrhagia. There were 5 cases of

amenorrhea which was of 7 months to 4 years duration. Four of the

patients had normal periods but there was a marked irritability with

inability to concentrate for as long as a week prior to the period.

p385

Of the 17 cases of oligomenorrhea, all reported definite relief as

long as they continued taking thyroid. Several of this group tried

going without therapy during the summer vacation but returned in the

fall asking to resume treatment because their symptoms had recurred.

All stated they felt much better when having their regular periods.

.....The group of patients who complained of amenorrhea is small due

to the fact that pathology was found to explain the cessation of

periods in many of those who had this complaint. Those patients

treated were given thyroid because their B.M.R. were low, and they

or their parents wished them to receive a trial with thyroid before

endometrial biopsies and further studies were made.

p386

Those patients complaining of menorrhagia and metrorrhagia responded

to thyroid therapy in a most satisfactory manner. The one failure

was in a patient who had a large ovarian cyst removed because of

prolonged menorrhagia.

.....V.C., a university junior 18 years of age, consulted the Student

Health Department because of a slight menstrual flow of six weeks

duration, early fatigue, and a tendency towards a rapid gain in

weight. She stated that her menstrual periods began when she was 13

and that they had always been irregular, occurring at intervals of

three weeks to several months (9 months at one time).

.....Treatment consisted of 1 to 2 gr. desiccated thyroid daily. The

B.M.R. rose to -5, blood pressure to 108/78; the bleeding stopped

and apparently normal periods occurred until the dose of thyroid was

reduced, when there was a recurrence of the metrorrhagia. This

patient has learned that she will have no symptoms I she takes

thyroid in sufficient dosage to keep her B.M.R. -5 or above. This

has been so consistent in her case that she can accurately predict

her B.M.R. will be below these levels when the metrorrhagia recurs.

p387

Four patients who complained of marked irritability prior to their

periods are included in this series because their complaint was

enough to interfere with their ordinary activities, and 3 did have

relief with thyroid. Two noted partial relief, enough so that they

did not want to stop thyroid medication. One had complete relief and

one noted no difference. Thyroid was stopped several times but

always with a recurrence of their symptoms.

.....

DISCUSSION

The explanation for the efficacy of thyroid medication in these

cases can only be hypothesized. Experimental work in animals has

shown that ablation of the thyroid is followed by an increase in

size of the pituitary gland. Microscopic examination of these

pituitaries shows hydropic degeneration, which explains the fact

that after this procedure glands lose some of their potency. It may

follow that in these patients there is an inadequate thyroid

secretion resulting in a decrease in potency of the pituitary gland,

which in turn causes inadequate gonad stimulation. One might go

farther and state that the 4 patients who noted breast engorgement

for the first time were having their first normal cycles with

luteinization occurring.

p388

Some of these problems may be solved by a study of endometrial

biopsies before and after treatment. In a group of patients as young

as these reported, most of whom are minors, it is difficult to

obtain permission for biopsies from the parent, but as the public

becomes educated to this procedure more parents should be willing to

consent.

It is our feeling that a B.M.R. should be obtained in all cases

complaining of menstrual irregularities such as those reported

above. Providing there is no pelvic pathology or physical condition

to explain the symptoms, these patients should probably receive a

trial with thyroid before further therapy is undertaken if their

metabolic rates are below zero. It is understood that these patients

will report periodically to their physicians and that the dose of

thyroid will depend upon the individual response. In many cases

there will be a complete relief of symptoms with small doses of

thyroid although the metabolic rate has not reached what is

considered the normal level. There is no way of predicting from the

individual B.M.R. the degree of relief to be obtained.

SUMMARY

Fifty patients with ages ranging from 16 to 34 years were seen

because of dysmenorrhea, oligomenorrhea, amenorrhea, metrorrhagia

and menorrhagia. All were apparently healthy individuals with normal

pelvic findings. These patients had B.M.R. ranging from -1 to -33

with an average of -15. All were treated with desiccated thyroid. Of

25 cases of dysmenorrhea 17 had complete relief, 5 partial, and 3 no

relief. Of 4 patients with amenorrhea lasting from 8 months to 4

years only one had relief of her symptoms. Among 13 patients with

metrorrhagia 12 had complete relief and of 7 with a menorrhagia 6

had complete relief. It is suggested that a B.M.R. should be

determined in those individuals complaining of menstrual

irregularities who have no demonstrable pathology to explain their

symptoms. A therapeutic trial of thyroid is indicated if the B.M.R.

is zero or below.

______________________

Author: BRODA O. BARNES M.D

Date Published: 01-Jan-1949

Publication: MEDICINE January, 1949, Vol. 6, No. 1 pp. 33-34

Title: THE TREATMENT OF MENSTRUAL DISORDERS IN GENERAL PRACTISE

Category: reproductive

Keywords: reproductive, problem, BARNES, TREAT, MENSTRUAL, DISORDER,

GENERAL, PRACTISE, thyroid, therapy, improve, patient, Basal,

Temperature, relieve, bleed, women

Text: The general practitioner can expect about 10 per cent of his

patients to complain of menstrual difficulties.

.....In 1939 and Thornton reported 50 cases of menstrual

irregularities treated with thyroid therapy. Their results were far

better than any published before or since. This present report of

143 cases is presented in confirmation of their work, and outlines

an inexpensive plan of management which produces gratifying results.

.....Control series for a group of cases of this kind are difficult.

Each case serves as its own control for the period before therapy.

Many of the patients relieved of their symptoms ceased medication

and in a few months would have a return of their previous

complaints. Thyroid therapy would again correct their menstrual

difficulty. In view of the fact that the number of patients who were

improved in the present series is almost identical, in proportion,

with that of and Thornton in 1939, it seems reasonable to

assume that the results are due to the treatment.

SUMMARY

One hundred forty-three cases of functional menstrual disorders have

been studied. Dysmenorrhea, excessive bleeding and irregular

menstrual cycles are included. The Basal Temperature usually is

subnormal. Thyroid therapy relieves the symptoms in about 90 per

cent of these cases.

_______________________

Author: JOSEPH C. SCOTT, JR., M.D.

Date Published: 01-Jan-1965

Publication: American Journal Obstetrics and Gynecology 90:161-165,

1965

Title: Menstrual patterns in myxedema

Category: reproductive

Keywords: reproductive, hypo, problem, pattern, myxedema, SCOTT,

hypo, gland, menstruation, mild, test, menstrual, thyroid, hormone,

menorrhagia, disease

Text: 161

HYPOFUNCTION of the thyroid gland produces a broad spectrum of

symptoms and signs, often including a change in the menstrual

pattern. The various disorders of menstruation which may be

associated with myxedema have been documented, but a difference

exists in the reported frequency and types of abnormal menstrual

pattern. Hypothyroidism has been implicated as the underlying cause

of many irregularities of menstruation.

.....Generally, it is believed that thyroid hormone is beneficial and

its use is indicated only when there is evidence of thyroid

hypofunction. A patient may be considered to be mildly hypothyroid

by one clinician and euthyroid by another on the basis of only a

single interview or test. No single test or procedure will define

the status of the thyroid gland. Furthermore, any combination of

methods may lead to erroneous interpretation or to inconsistent

results. The clinician must have the faculty of correlating the

clinical appearance of the patient with the laboratory findings.

p 164

.....Comment

Menorrhagia, that is, an increase in the amount and duration of

menstrual flow, associated with myxedema may be mild, " occult, " or

severe. Mild menorrhagia is a source of only minor concern and

usually is corrected by better control of the myxedematous state.

The term " occult menorrhagia " is warranted in cases in which there

is excessive or prolonged menstruation which the patient considers

to be normal. In these cases the onset of the menorrhagia has been

so insidious that the patient is truly unaware of the change unless

questioned closely (Case 2). Severe menorrhagia may require

diagnostic curettage in addition to thyroid replacement therapy.

Thyroid dysfunction should be considered in evaluation of each case

of menstrual irregularity. Our studies reinforce the observations of

other authors that menstrual disorders are not unusual in myxedema.

A careful gynecologic examination should be performed for each

patient suspected of having a thyroid disease. Any menstrual

disorder should not be minimized and the possibility of genital

malignant disease should be considered.

Laboratory studies have greatly aided the clinicians in defining and

evaluating thyroid disease states, but the " clinical appearance " of

the patient should continue to be a prime factor in evaluation.

Diagnostic measures, such as the quantitation of menstrual blood

loss by tagging with radioactive chromium, are useful and

informative in many patients, but not indispensable.

Menorrhagia is the most frequent of the menstrual aberrations which

are associated with myxedema. Hypomenorrhea and amenorrhea are much

less common, and we have found oligomenorrhea to be rare.

p 165

Summary

The menstrual patterns of 50 premenopausal myxedematous women

between 16 and 40 years of age were evaluated. Abnormal menstrual

patterns occurred in 56 per cent of these patients. More than one

form of menstrual irregularity was noted in two cases. Menorrhagia

and metrorrhagia, alone or combined, constituted the abnormal

patterns in 75 per cent of the patients.

Amenorrhea occurs infrequently with myxedema. " Occult " menorrhagia

should be considered in the evaluation of the patient with thyroid

disease.

_______________________

Author: Longcope

Date Published: 30-Jun-1996

Publication: Werner and lngbar's The Thyroid, Seventh Edition,

edited by E. Bravennan and D. Utiger. Lippincott-~ven

Publishers, Philadelphia, @ 1996

Title: 71 The Male and Female Reproductive Systems in Hypothyroidism

Category: reproductive

Keywords: Longcope, reproduction, uterus, ovaries, hypo, thyroid,

endometrial, muscle, animal, human, fertility, sexual, vagina,

precocious, puberty, fetal, abort, testicular, sperm, libido

Text: 849

HYPOTHYROIDISM IN THE FEMALE REPRODUCTIVE SYSTEM

Hypothyroidism seems to affect the reproductive system in women more

than in men. A review of the normal develop- ment and physiology of

the female reproductive system has been given in chapter 47.

Animal Studies

In sheep, fetal hypothyroidism does not affect reproductive tract

development but does result in prolonged gestation despite maternal

euthyroidism.l However, in the rat, fetal hypothyroidism results in

small ovaries deficient in lipid and cholesterol.2 Thyroidectomy of

sexually immature rats results in delayed vaginal opening and sexual

maturation; smaller ovaries and follicles than in controls3,4; and

uteri and vaginas that are not well developed.5

When adult female rats are rendered hypothyroid their estrous cycles

become irregular and their ovaries become atrophic.6 There is an

enhanced response to HCG with the development of large cystic

ovaries in hypothyroid rats.7 Hypothyroidism in hamsters and cows is

associated with abnormal estrous cycles,s.9 and in hypothyroid hens

there is a decrease in egg production.9

In the mature female rat, hypothyroidism apparently does not result

in sterility but does interfere with gestation, especially in the

fIrst half of pregnancy,lO with resorption of the embryo and

subsequent reduction in litter size and an increase in

stillbirths.ll

In hypothyroid sheep, the uterus shows endometrial hyperplasia and

smooth muscle hypertrophy, perhaps related to the prolonged estrous

noted in hypothyroid ewes.12 Ruh and coworkers 13 reported increased

estradiol binding in uteri of hypothyroid rats, but Kirkland and

coworkers 14 found a decrease in the uterine response to estrogen in

hypothyroid rats.

Hypothyroidism inhibits the photoperiod responses and seasonal

breeding patterns in sheep and birds.15,16

Human Studies and Clinical Aspects

The reproductive tract appears to develop normally in cretins; thus,

hypothyroidism during fetal life does not appear to affect the

normal .development of the reproductive tract. Hypothyroidism in

prepubertal years generally leads to short stature and may lead to a

delay in sexual maturity.4 However, an interesting syndrome

described by Kendlell and Van Wyk and Grumbach 18 occurs not

infrequently: it is characterized by precocious menstruation,

galactorrhea, and sella enlargement in girls with juvenile

hypothyroidism. The cause is thought to be an overlap in the

pituitary production of TSH and gonadotropins, with the latter

causing early ovarian secretion of estrogens and subsequent

endometrial stimulation with vaginal bleeding. Prolactin levels are

elevated, leading to galactorrhea. However, there is no pubertal

increase in the adrenal production of androgen precursors, so that

axillary and pubic hair are usually not apparent.I8 Therapy with

thyroxine in proper dosage results in prompt alleviation of the

symptomatology.

In adult women, hypothyroidism results in changes in cycle length

and amount of bleeding I9-21 and has been reported

850

in association with the ovarian hyperstimulation syndrome.22

Menorrhagia is a frequent complaint and is probably due to estrogen

breakthrough bleeding secondary to anovulation, which is frequent in

severe hypothyroidism. 19 The anovulation is reflected in the

frequent finding of a proliferative endometrium on endometrial

biopsy.23 TRa-l and TRBB-1 receptors have been found in human

granulosa cells and both triiodothyronine and thyroxine have been

found in follicular fluid.24 Earlier work in- dicated that thyroxine

enhanced the action of gonadotropins on luteinization and progestin

secretion by cultured granulosa cells,25 and it has recently been

noted that in a group of infertile women, those with elevated TSH

levels had a higher incidence of out-of-phase biopsies than women

with normal TSH.26 Ovulation and conception can occur in mild

hypothyroidism, but in the past those pregnancies that did occur

were often associated with abortions in the first trimester,

stillbirths, or prematurity, 19,27 Recent studies indicate these

events may be less common but that gestational hypertension occurs

often in pregnant women with untreated hypothyroidism.28 Pregnancy

occurring in women with myxedema has been reported to be uncommon,27

but this is somewhat hard to document and may be the result of

anovulation. The use of L-thyroxine is not helpful in treating

euthyroid patients for infertility, menstrual irregularity, or the

premenstrual syndrome.29,30

In evaluating the thyroid status of the pregnant woman, the level of

TSH is probably the best indicator of changes in thyroid function.

Because radioiodine will readily cross the placenta and can cause

fetal hypothyroidism, tests involving ra- dioiodine administration

to the mother are contraindicated in pregnancy.19 When

hypothyroidism is diagnosed during pregnancy, L-thyroxine therapy

should be instituted promptly to increase the chances for a normal

pregnancy. Although it has been thought that little L-thyroxine

would cross the placenta,19 it appears that L-thyroxine will cross

the placenta in modest amounts,31 at least early in pregnancy. Women

who have required thyroid hormone therapy prior to pregnancy should

continue with such therapy throughout the pregnancy. How- ever,

recent evidence indicates that the hormone dose needs to be

increased during pregnancy, even though adequate replacement had

been given before conception.31 It is advisable to monitor the serum

TSH concentration at least once during each trimester to ensure that

an adequate dose is received. Thyroid disease during and after

pregnancy is discussed in detail in chapter 89.

Some myxedematous women will present with amenorrhea and

galactorrhea and elevated serum prolactin concentrations.19 Thus,

thyroid evaluation should be an essential part of the work-up in any

person with galactorrhea. If hypothyroidism is the cause, the

amenorrhea and galactorrhea and elevated serum prolactin will

disappear promptly with thyroxine therapy.32

There is an increased incidence of Hashimoto's thyroiditis in

individuals with 's syndrome,33 and, although a chromosomal

linkage between autoimmtme disease and the X- chromosome has been

suggested, this has not been confirmed.34 Inherited abnormalities in

serum thyroxine-binding globulin (TBG) are X-linked, and patients

with 's syndrome may ,have low serum TBG values.35

Women with hypothyroidism have decreased metabolic clearance rates

of androstenedione and estrone and increased peripheral

aromatization.36 The ratio of 5a/5B metabolites of androgens is

decreased in hypothyroid women, and there is an increase in the

excretion of estriol and a decrease in the excretion of 2-oxygenated

estrogens.37

In summary, hypothyroidism in girls can cause alterations in the

pubertal process; this is usually a delay, but occasionally it can

result in pseudoprecocious puberty. In mature women, hypothyroidism

usually is associated with abnormal menstrual cycles, especially

anovulatory cycles, and an increase in fetal wastage.

HYPOTHYROIDISM IN THE MALE EPRODUCTIVE SYSTEM

The normal development and physiology of the male reproductive

system has been described in chapter 47. Although less common in men

than in women, hypothyroidism, induced or spontaneous, affects the

male reproductive tract in a number of ways depending, in part, on

the age of onset.

Animal Studies

The fetal thyroid starts functioning about the same time as the

gonads.38 Although thyroid hormones play role in sex differentiation

and gonadal maturation in fish and amphibians,39 they do not appear

to be necessary for the normal development of the reproductive tract

in mammals. 1

However, hypothyroidism, induced or occurring soon after birth, is

associated with a marked delay in sexual maturation and

development.40 When rats are made hypothyroid with propylthiouracil

administered from birth to 24 to 26 days of age, testicular size is

decreased, Sertoli cell differentiation is retarded, and the time of

Sertoli cell proliferation is prolonged.4].42 As these rats become

older and euthyroid, then the testis size, Sertoli cell number, and

sperm production are all increased.41, Leydig cell numbers are

increased but testosterone secretion per cell is decreased, although

total testosterone secretion remains the same as controls.43 FSH and

LH levels tend to remain low throughout treatment and recovery

periods, whereas inhibin levels are elevated.41

However, if hypothyroidism persists untreated, there is an arrest of

sexual maturity with absent libido and ejaculate.44 The interstitial

cells of the testis are reduced in number and the arrested growth of

the accessory male sex organs indicates a decrease in the production

of testosterone.44 The longer the hypothyroidism persists, the

greater the degree of damage to the testes,44 although genetically

induced hypothyroidism in male mice is associated with normal

fertility .45

In the adult ram, hypothyroidism is associated widl a decrease in

testosterone concentration but normal spermatogenesis.46 In the

mature male rat, the induction of hypothyroidism has little effect

on the pathology of the testes, sperlllatogenesis, or serum testos-

terone concentrations.47 Thus, it would appear that hypothyroidism

can affect the immature, but not the mature, testis.

Human Studies and Clinical Aspects

The development of hypothyroidism in the male fetus does not appear

to affect the reproductive system. Cretins are usually born with a

normally developed reproductive tract. The presence of

hypothyroidism in the prepubescent years usually results in a delay

of sexual maturation and of the whole pre-pubertal process, which

can be overcome by the administration of adequate doses of

thyroxine. However, in some instances, hypothyroidism can result in

precocious pseudopuberty marked by the early development of external

genitalia, but without the appearance of axillary and pubic hair. 48

This syndrome probably results from an increased secretion of

gonadotropins along with TSH from the enlarged pituitary.48

In men, hypothyroidism has been suggested as a cause of

infertility,49 but there is considerable disagreement with this

suggestion. 50 If an infertile man is found to be hypothyroid, one

should suspect secondary hypothyroidism and pituitary disease rather

than primary myxedema, and there is no reason to treat infertile

euthyroid men with thyroid hormone.50

In hypothyroid men, testicular size and potency may be normal and,

despite early reports of defective spermatogenesis in

hypothyroidism, 51 semen analysis is usually normal.52 Wortsman and

colleagues reported that myxedema was often associated with

infertility and impotence, but in this report the impotence did not

improve when the men became euthyroid.49 In addition, there was a

decrease in serum testosterone and free testosterone and, in the men

who were not over-weight, an increase in sex hormone-binding

globulin. It should be noted that sex hormone-binding globulin

levels have also been reported as both decreased53 and normal 54 in

hypothyroid men. Many men with hypothyroidism do note a decrease in

libido, but this is probably a nonspecific disease-related

complaint, which disappears when the euthyroid state is achieved

with thyroid replacement therapy.

Variations in testis size and histology have been noted in autopsy

material,55,56 and De La BaIze and coworkers 51 noted Leydig cell

hyperplasia and tubular hyalinization. There is a marked decrease in

the 5a/5B ratio of the metabolites of androstenedione and

testosterone, which is the reverse of that seen in hyperthyroidism

57

In summary, although hypothyroidism in boys frequently interferes

with the normal pubertal process, the development of hypothyroidism

in men has a less clear-cut effect on the reproductive system.

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56. Marine D. Changes in the interstitial cells of the testis in

Gull's disease. Arch PathoI1939;28:65

____________________________

Author: Sheldon S. StofIer. MD

Date Published: 01-Jan-1982

Publication: POSTGRADUATE MEDICINE. VOL 72/NO 2/AUGUST 1982

Title: Menstrual disorders and mild thyroid insufficiency Intriguing

cases suggesting an association

Category: reproductive

Keywords: reproductive, problem, StofIer, Menstrual, disorder, mild,

thyroid, insufficiency, case, suggest, association, pathology,

patient, treat, levothyroxine, hypo, hyper, TSH, TRH

Text: Should patients with menstrual dysfunction but without obvious

uterine pathology be considered for thyrotoxin-releasing hormone

(TRH) testing? In several cases described here. an apparent

relationship between menstrual disturbance and minimal thyroid

insufficiency was documented by the patients' dramatic response to

treatment with levothyroxine.

The association of overt hypothyroidism or hyperthyroidism with

menstrual disturbance and infertility is well known.15 However,

menstrual disturbance may also be related to minimal thyroid

insufficiency, as the following cases suggest.

The past ten years have brought enonnous advances in the ability to

diagnose mild thyroid dysfunction. The introduction of serum

thyroxine and serum thyroid -stimulating hormone (TSH)

radioimmunoassays has increased the sensitivity and specificity of

thyroid function testing. The serum TSH assay has been shown to be a

sensitive indicator of diminished thyroid functional reserve. since

TSH levels become elevated before circulating serum thyroxine levels

fall below the normal range 6,

Thyrotropin-releasing hormone (TRH) is a simple tripeptide nonnally

found in the hypothalamus. Its availability in synthetic fonn,

protirelin (Thypinone, Relefact TRH), has provided a convenient

provocative test of pituitary TSH reserve and has further extended

the sensitivity of thyroid testing. In fact, this TRH test is so

sensitive that results may be markedly abnormal in patients with no

signs or symptoms of thyroid disease.6 Patients with minimal

impairment of thyroid functional reserve who have normal serum

thyroxine and normal baseline serum TSH levels may have an augmented

TSH response to TRH administration.6

76

Table 1. Results of thyroid function studies in four patients with

menstrual disturbance treated by levothyroxine therapy

Case Time of testing Thyroid function study

FTI* Baseline TRH:+

TSHt

1 Initial study 2.2 6.0 58.0

After26mo of treatment 2.9 3.0 11.7

2 Initial study 1.9 7.1 57.3

After 6 mo of treatment 3.5 1.6 1.8

3 Initial study 1.7

Two years later 2.1 7.2 52.9

After 3 mo of treatment 2.0 1.2

After 21 mo of treatment 2.6 2.8 14.3

4 Initial study 1.8 9.3 >80

After2 mo of treatment 3.8 3.0 6.1

After 14 mo of treatment 1.7 16.4 >80

After 2 mo of increased 3.6 2.5 2.5

dosage

* Free thyroxine index (total T4 x T3 resin uptake). normal range

1.4-4.0

+Thyroid-stimulating hormone by radioimmunoassay, normal <8.0 uU/mc

tThyrotropin-releasing hormone test (serum TSH rise 20 min after

administration of 100 ug TRH), normal range 2-20 uUI ml

80

......

Discussion

In the past, when thyroid test-ng was nonspecific, inaccurate, and

insensitive, desiccated thyroid tablets were often given empirically

to women with menstrual dysfunction and/ or infertility. Some of

these patients may have improved, reinforcing this unscientific and

currently unjustifiable approach. At least a portion of these women

may have actually had subclinical, and at that time undetectable,

thyroid insufficiency.

......

Recently, I encountered a 32 year-old patient with evidence of very

mild thyroid insufficiency who had undergone hysterectomy four years

before because of troublesome hypermenonorrhea The patient had a

diffuse goiter 11/2 times normal size, and antimicrbsomal antibodies

were positive at 1:6,400 dilution. Serum FTI was 1.5, baseline serum

TSH was 6.3 µU/m1, and serum TSH 20 minutes after TRH administration

was 60.7 µU/m1. The pathology report revealed a normal-sized uterus

With a predominantly proliferative endometrium and a normal

myometrium. Although mild thyroid dysfunction cannot be proven

responsible for this patient's abnormal menstrual bleeding, one

wonders if TRH testing could have avoided the need for hysterectomy

in this case and perhaps in similar cases.

......

82

......

Recommendations

Based on my experience, I would recommend that patients \vith long-

standing menstrual dysfunction without obvious uterine pathology be

considered for TRH testing. Such testing would be especially

fruitful in patients with goiter, high-nrmal baseline serum TSH

value, or family history of thyroid disease. I would certainly not

encourage empirical use of thyroid hormone in such a patient

population without appropriate testing. Because mild thyroid

insufficiency is so easily treated, TRH testing and atrial of

thyroid hormone therapy, if .indicated, should be considered in

difficult cases of menstrual dysfunction prior to hysterectomy.

Summary

Three cases of menstrual disturbance possibly related to minimal

thyroid insufficiency are reported. In all cases, tltyrotropin-

releasing hormone testing was sensitive enough to detect evidence of

tltyroid abnormality .Without exception, treatment with

levothyroxine caused a dramatic end to menstrual difficulty. In two

of these cases, levotltyroxine tlterapy was discontinued and the

menstrual abnormality returned.

Resumption of levotltyroxine treatment led to prompt retum of normal

menstruation. A fourth case is presented which suggests tltat

placebo effect alone is probably not responsible for the observed

menstrual improvement. It is possible that minimal thyroid

insufficiency can lead to marked menstrual disturbance.

References

I. Goldsmith RE. Sturgis SH. Lennan J. et a!. The menstrual pattern

in thyroid disease J Clin Endocrinol Metab 1952 12: 846-55

2. Distiller LA. Sage1 J. Morley JE. et a!. Assess ment of pituitary

gonadotropin reserve using luteinizing hormone releasing hormone

(LRH) in states of altered thyroid function J Clin Endocrinol Metab

1975:40, 512-15

3. Keye WR. Yuen BH. KnopfRF. et a!. Amenorrhea yperprolactinemia,

and pituitary enlargement secondary to primary hypothyroidism Obstet

Gyneco 1976:48,697-702

4. Van Wyk JJ. Grumbach MM. Syndrome of precocious menstruation and

galactorrhea in juvenile hypothyroidism an example of hormonal

overlap in pituitary feedback J Pediatr 1960:57,416-35

5. Tolis G. Hoyte K. McKenzie JM. et al. Clinical.biochemical and

rndlologic reversibility of hyperprolactinemic

galactorrhea.amenorrhea and abnorma sella by thyroxine in a patient

with primary hypothyraidisrn Am J Obstet Gynecol 1978:131, 850-2

6. Ingbar SH. Woeber KA. The thyroid gland In: Willams R. ed,

Textbook of endocrinology 6th ed Philadelphia WB Saunders, 1981: 117-

247

7. Buchanan GC. Tredway DR. Pittard JC. et a!.Gonadotropin secretion

and hypothyroidism Obstet Gynecol 1977: 50,392-6

S. CoUu R. Abnormal pi tui tary hormone response to thyrotropin-

reieasing hormone an index. of central nerve system dysfunctlon In

Tolis G, Labrle, F JB, et al. eds Cllnical neuroendocrinology

a pathophysiological approach New York Raven Press 1979: 129-37

9. Snyder PJ. s LS. Utige RD et al. Thyroid hormone inhibitlon

of the prolactin response to thyrotropin-releasing hormone J Clin

Invest 1973: 52,2324-9

10. Tolls G. Prolactin physiology and pathology In: Krieger DT

JC eds Neuroendocrinology Sunderland. MA Sinauer Assoc, 1980:

34,322-8

11. Powers JM. Block MB. Primary hypothyroidlsm with reversible

hypeprolactinemia and pituitary enlargement Ariz Med 1989:37, 256-8

12. Stoffer SS. McKee1 DW Jr. Randall RV, et a!. Pituilary prolactin

cell hypetplasia with autonomous prolactin secretlon and primary

hypothytoidism Fertil Steril 1981: 36,682-5

__________________

Author: Luoto R

Date Published: 27-Jun-1997

Publication: Int J Epidemiol 1997 Jun;26(3):476-83

Title: Hysterectomy and subsequent risk of cancer.

Category: reproductive

Keywords: Luoto, Hysterectomy, subsequent, risk, cancer, Elevate,

papillary, thyroid, follow, reproductive, endocrinological, cause,

high, breast, peri, retrospective, study, menopause, total, pre

Text: BACKGROUND: The objective of this retrospective cohort study

was to assess the effect of hysterectomy on subsequent risk of

cancer among 25,382 hysterectomized and a similar number of non-

hysterectomized control women, registered in 1963-1976 in the Mass

Screening Registry (MSR).

METHODS: Cancer cases were obtained from the Finnish Cancer Registry

(FCR) and standardized incidence ratio (SIR); the expected number of

cases based on cancer incidence rates of the Finnish female

population in 1967-1993, was used. Relative risk (RR) was calculated

as SIR among the hysterectomized relative to non-hysterectomized

women, adjusted for follow-up, education and parity.

RESULTS: The RR estimates of non-genital cancers among women with

any hysterectomy were approximately 5% higher than in the non-

hysterectomized cohort. Relative risks of rectal cancer (RR = 1.4,

95% confidence interval [CI]: 1.0-1.8) and thyroid cancer (RR = 2.1,

95% CI; 1.5-3.1) were significant and largest among women who had

undergone total hysterectomy pre- or perimenopausally. Relative risk

estimates of breast cancer were close to unity.

CONCLUSIONS: Hysterectomy is not associated with any substantial

protective or promoting effect on cancers in general. Elevated risk

of papillary thyroid cancer following hysterectomy is biologically

plausible, as there are reproductive and endocrinological causes of

thyroid cancer.

National Public Health Institute, Department of Epidemiology and

Health Promotion, Helsinki, Finland.

PMID: 9222770 [PubMed - indexed for MEDLINE]

_____________________

March 18, 2005