Highlights • Estrapel is an oestradiol implant that provides a non-oral treatment option for menopausal hormone therapy. • Its prolonged action makes patient selection important, as the implants ...cannot easily be removed. • In women with an intact uterus, the continuation of progestin therapy after cessation of implant therapy is imperative.
T4 is standard treatment for hypothyroidism. A recent study reported that combined T4/liothyronine (T3) treatment improved well-being and cognitive function compared with T4 alone. We conducted a ...double-blind, randomized, controlled trial with a crossover design in 110 patients (101 completers) with primary hypothyroidism in which liothyronine 10 μg was substituted for 50 μg of the patients’ usual T4 dose. No significant (P < 0.05) difference between T4 and combined T4/T3 treatment was demonstrated on cognitive function, quality of life scores, Thyroid Symptom Questionnaire scores, subjective satisfaction with treatment, or eight of 10 visual analog scales assessing symptoms. For the General Health Questionnaire-28 and visual analog scales assessing anxiety and nausea, scores were significantly (P < 0.05) worse for combined treatment than for T4 alone. Serum TSH was lower during T4 treatment than during combined T4/T3 treatment (mean ± sem, 1.5 ± 0.2 vs. 3.1 ± 0.2 mU/liter; P < 0.001), a potentially confounding factor; however, subgroup analysis of subjects with comparable serum TSH concentrations during each treatment showed no benefit from combined treatment compared with T4 alone. We conclude that in the doses used in this study, combined T4/T3 treatment does not improve well-being, cognitive function, or quality of life compared with T4 alone.
Erectile and endothelial dysfunction are common in individuals with multiple cardiovascular risk factors and are longitudinal predictors of cardiovascular events. The pathogenesis of both endothelial ...and erectile dysfunction is intimately linked through increased expression and activation of endothelial nitric oxide synthase, and the subsequent physiological actions of nitric oxide. Endothelial production of nitric oxide by endothelial nitric oxide synthase in the corpus cavernosum is involved in the maintenance of penile erection. Erectile dysfunction can be detected clinically using systematic questioning and could potentially be employed as an independent predictor of cardiovascular risk to target treatment of cardiovascular risk factors. Both erectile and endothelial dysfunction respond to lifestyle modifications, particularly in individuals with the metabolic syndrome. Drugs that improve endothelial dysfunction can also improve erectile dysfunction, but responses are not always concordant. Phosphodiesterase type 5 inhibitors, however, are powerful agents that commonly improve erectile and endothelial dysfunction, with potential cardiac applications. The recent Princeton consensus requires more extensive implementation and evaluation in clinical practice. The judicious diagnosis of erectile dysfunction, nevertheless, provides a unique opportunity for the prevention of cardiovascular disease.
Objective Our objective is to report observed changes in thyroid-stimulating hormone (TSH) in two patients undergoing super-ovulation for IVF. Design Case report. Setting Private assisted ...reproduction practices. Patient(s) Two hypothyroid women taking thyroxine replacement therapy undergoing super-ovulation for IVF. Intervention(s) Laboratory records for TSH taken during ovulation induction cycles were retrieved retrospectively for six cycles and measured prospectively for one cycle each in both women. Main Outcome Measure(s) To document changes in thyroid status during super-ovulation. Result(s) Despite being euthyroid at the start of the super-ovulation cycle, both patients demonstrated a rise in TSH to hypothyroid levels during ovulation induction, even in the absence of ongoing pregnancy. Conclusion(s) High circulating E2 during super-ovulation for IVF induces increased thyroxine-binding globulin binding of thyroxine. In women taking thyroxine replacement therapy, hypothyroidism develops during a super-ovulation cycle. Whether such acute biochemical hypothyroidism is a hindrance to ovum quality, fertilization, conception, or ongoing pregnancy and whether thyroxine dose adjustment during a super-ovulation cycle would improve IVF outcomes requires further study. These case studies identify a potential management gap in assisted reproduction for women taking thyroxine therapy.
Summary
Background Women with polycystic ovarian syndrome (PCOS) commonly consult endocrinologists or gynaecologists and it is not known whether these specialty groups differ in their approach to ...management.
Objective To compare the investigation, diagnosis and treatment practices of endocrinologists and gynaecologists who treat PCOS.
Design and Setting A mailed questionnaire containing a hypothetical patient's case history with varying presentations − oligomenorrhoea, hirsutism, infertility and obesity − was sent to Australian clinical endocrinologists and gynaecologists in teaching hospitals and private practice.
Results Evaluable responses were obtained from 138 endocrinologists and 172 gynaecologists. The two specialty groups differed in their choice of essential diagnostic criteria and investigations. Endocrinologists regarded androgenization (81%) and menstrual irregularity (70%) as essential diagnostic criteria, whereas gynaecologists required polycystic ovaries (61%), androgenization (59%), menstrual irregularity (47%) and an elevated LH/FSH ratio (47%) (all P‐values < 0·001). In investigation, gynaecologists were more likely to request ovarian ultrasound (91%vs. 44%, P < 0·001) and endocrinologists more likely to measure adrenal androgens (80%vs. 58%, P < 0·001) and lipids (67%vs. 34%, P < 0·001). Gynaecologists were less likely to assess glucose homeostasis but more likely to use a glucose tolerance test to do so. Diet and exercise were chosen by most respondents as first‐line treatment for all presentations. However, endocrinologists were more likely to use insulin sensitizers, particularly metformin, for these indications. In particular, for infertility, endocrinologists favoured metformin treatment whereas gynaecologists recommended clomiphene.
Conclusions There is a lack of consensus between endocrinologists and gynaecologists in the definition, diagnosis and treatment of PCOS. As a consequence, women may receive a different diagnosis or treatment depending on the type of specialist consulted.
Premature ejaculation (PE) is the most common ejaculatory dysfunction. We assessed the efficacy of sildenafil to increase the time to ejaculation, improve ejaculatory control, and decrease the ...postejaculatory erectile refractory time in men with PE.
The main study was an 8‐week, double‐blind, placebo‐controlled, parallel group study in men between 18 and 65 years of age with diagnosed PE. A substudy was also conducted using a subset of patients (two‐way crossover, one center) before entry to the main study. The primary study measured intravaginal ejaculatory latency (IELT) and responses to the Index of Premature Ejaculation (IPE) questionnaire. The substudy measured vibrotactile stimulation ejaculatory latency time (VTS‐ELT) and postejaculatory erectile refractory time. Differences between treatment groups were determined by ancova at the 5% level of significance.
The change in IELT (1.6 ± 6.08 vs. 0.6 ± 2.07 minutes) and VTS‐ELT (2.9 ± 0.4 vs. 2.4 ± 0.4 minutes) were higher after taking sildenafil, compared with placebo, but did not reach statistical significance. However, patients who took sildenafil (vs. placebo) reported significantly (P < 0.05) increased ejaculatory control (1.8 ± 0.3 vs. 1.5 ± 0.3), increased ejaculatory confidence (2.2 ± 0.2 vs. 1.9 ± 0.2), and improved overall sexual satisfaction scores (3.1 ± 0.2 vs. 2.8 ± 02) on the IPE, and had a decreased postejaculatory erectile refractory time (3.2 ± 0.7 vs. 6.4 ± 0.7 minutes). The most common adverse events for sildenafil (vs. placebo) were headache (15% vs. 1%), flushing (15% vs. 0%), dyspepsia (5% vs. 1%), abnormal vision (5% vs. 0%), and rhinitis (5% vs. 0%).
Although IELT and VTS‐ELT were not significantly improved, sildenafil increased confidence, the perception of ejaculatory control, and overall sexual satisfaction, and decreased the refractory time to achieve a second erection after ejaculation in men with PE.
In the 5-10% of diabetic men with type 1 diabetes, erectile dysfunction (ED) may be a particularly common and unwanted complication. This is the first study focusing exclusively on the effects of ...sildenafil in men with type 1 diabetes and ED.
A total of 188 patients were entered into a double-blind, placebo-controlled, parallel-group, flexible-dose study and were randomized to receive sildenafil (25-100 mg; n = 95) or placebo (n = 93) for 12 weeks. Efficacy was evaluated using questions three (Q3; achieving an erection) and four (Q4; maintaining an erection) from the International Index of Erectile Function (IIEF), a global efficacy question (GEQ; "Did treatment improve your erections?"), and a patient event log of sexual activity.
Improvements in mean scores from baseline to end-of-treatment for IIEF Q3 (35.7 vs. 19.9%) and Q4 (68.4 vs. 26.5%) were significant in patients receiving sildenafil compared with those receiving placebo (P = 0.0001). Moreover, the percent of improved erections (GEQ, 66.6 vs. 28.6%) and successful intercourse attempts (63 vs. 33%) was significantly increased with sildenafil compared with placebo. Improvements in sexual function were seen irrespective of the degree of ED severity. Adverse events were generally mild to moderate in severity, with headache (20 vs. 8%), flushing (18 vs. 3%), and dyspepsia (8 vs. 1%) reported more often in the sildenafil than in placebo-treated patients.
Treatment with sildenafil for ED was effective, resulting in an increased percentage of successful attempts at intercourse, and was well tolerated among men with type 1 diabetes.
Increasing numbers of women have menopausal symptoms after treatment for breast cancer. These symptoms can result directly from cancer treatments (such as oophorectomy, ovarian suppression, ...chemotherapy-induced ovarian failure, and antioestrogens), as a spontaneous event, or after discontinuation of hormone-replacement therapy. The onset of menopausal symptoms after treatment for breast cancer can have a long-lasting effect on quality of life, body image, sexual function, and self esteem. Hormone-replacement therapy that contains oestrogen is the most effective treatment for menopausal symptoms in healthy women. However, evidence from one randomised controlled trial suggests that use of hormone replacement therapy after breast cancer raises the risk of recurrence and of new primary breast cancer. As the incidence of breast cancer increases and survival continues to improve, the number of women with menopausal symptoms will probably rise. Safe and effective non-hormonal treatments for severe menopausal symptoms after breast cancer are urgently needed. Few studies have addressed the management of menopausal symptoms after breast cancer, and the quality of studies is generally poor. Progestagens, and selective inhibitors of serotonin and norepinephrine reuptake seem to offer reasonable symptom palliation, but the long-term effectiveness and safety of these preparations is not known. We propose that the management of menopausal symptoms in patients with a history of cancer requires a patient-centred, but multidisciplinary, approach.
Premature ejaculation (PE) is ejaculation occurring without control, on or shortly after vaginal penetration and before the subject wishes it, causing marked distress or interpersonal difficulties.
...PE is the most common male sexual complaint. Primary (lifelong) PE has a physiological basis.
Therapy should involve the man and his partner. The primary aims of therapy are for the man to regain a sense of control over his ejaculation time and for him and his partner to feel satisfaction with sexual intercourse.
The most effective therapies for primary PE are certain selective serotonin reuptake inhibitors, given on a daily basis or “on demand” before sexual activity. Topical anaesthetics have also been shown to be effective.
The most common cause of secondary PE is declining erectile function. The approach to treating secondary PE is to treat the underlying condition.
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