The Natural Thyroid Diet

Thyroid Factor

Thyroid Factor is a program that was created by Dawn Sylvester to help women deal with thyroid issues. Dawn Sylvester is a 57 years old lady that has worked with 1,000's of real women. She has over the time tried to investigate the underlying reason why majority of women lose energy and also struggle with belly fat and fatigue as they age. It is a comprehensive program thatcomprises of Thyro pause, 11 kinds of thyroid saving foods that will work to help you boost fat burning Free T3. The program also teaches you all the hidden causes of thyroid which are making you fat and later a highly reliable Thyroid reboot plan which is an excellent plan you need to tackle your weight. Additionally, there are tips to reduce bulging fat fast and eventually obtain a healthy body. You also get several bonuses all aimed at helping you solve all the problems that comes with being overweight. The three bonuses you get are 21 Day Thyroid weight loss system, 101 Thyroid boosting foods and Thyroid Jumpstart Guide. Read more...

Thyroid Factor Summary


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2155 Thyroid function and iodine supply during pregnancy

During pregnancy, there are hormonal and metabolic changes that require an adaptation of thyroid function. A healthy pregnant woman can easily compensate for this change. The adaptation is an important prerequisite for normal embryonic and fetal development, and also for an uncomplicated pregnancy. The fetal thyroid begins to function at the end of the third month of pregnancy (Burrow 1994). Before that, the embryo is exclusively dependent on the thyroid supply via the mother. During pregnancy, the mother's need for iodine increases because the thyroid function of the fetus, as well as the mother, is dependent on a sufficient iodine supply.

2156 Hypothyroidism triiodothyronine T3 and thyroxine T4

According to a recent study on 60 hypothyroid women (whose disease was only diagnosed after 12 weeks of pregnancy), hypothyroidism impaired the mental and motor capacities of their children, who were tested at the age of 2 years compared to children of euthyroid or only discrete hypothyroid women during pregnancy (Pop 2003). Haddow (1999) draws similar conclusions from his study on 60 children aged 7-9 years. Their mothers only suffered from discrete hypothyroidism during pregnancy. Based on these results, hypofunction of the thyroid should be diagnosed and treated for the benefit of Lhe developing unborn child. Regarding the risk of neonatal hypothyroidism after maternal thyrostatic therapy during pregnancy, sec section 2.15.7. Hormonally effective thyroid hormones are the L-forms of triiodothyronine (T3) and thyroxine (T4), which are only metaboli-cally active in a free, non-protein-bound form. T3 is the biologically effective hormone with a short period of effectiveness, while T4...

Thyroid function tests

Measurement of serum TSH is the most practical, simple, and economic screening test for thyroid dysfunction. Serum TSH concentrations are dependent on gestational age it is lower in the first trimester as compared to the second and third trimester of pregnancy. There is significant clinical data at the present time to support a serum TSH value of 2.5 mIU L as the upper limit of normal in first trimester of pregnancy, the lower limit of normal is 0.1 mIU L.1 There is a fairly good inverse correlation between TSH and hCG concentrations. As mentioned above, low or suppressed TSH values are present in about 15 of pregnant women in the first trimester of gestation. In the presence of an abnormal serum TSH value, the determination of FT4 or its equivalent free thyroxine index (FT4I), is necessary for the proper assessment of thyroid function. A word of caution regarding the determination of free thyroxine levels in different trimesters of pregnancy. There is a significant inconsistency...

Euthyroid chronic thyroiditis

Patients with Hashimoto's thyroiditis are at greater risk of developing hypothyroidism very early in pregnancy because of the increase demand in thyroid hormones if not properly managed they are at risk of developing the same complications as poorly treated hypothyroid mothers, mainly spontaneous abortions, preterm delivery, and pregnancy-induced hypertension (PIH). One recent study showed a significant decrease of miscarriages and preterm delivery in euthyroid chronic thyroiditis women treated with levo-thy-roxine in the first 10 weeks of gestation as compared to euthy-roid chronic thyroiditis mothers receiving no treatment and a control population.13 In the untreated women a significant number of them developed subclinical hypothyroidism. Therefore it appears reasonable to treat euthyroid and subclinical hypothyroidism mothers with levo-thyroxine before or very early in pregnancy to prevent the above complications.

Transient hyperthyroidism of hyperemesis gravidarum

One of the most clinically recognized forms of gestational thyrotoxicosis is transient hyperthyroidism of hyperemesis gravidarum (THHG). It is characterized by severe nausea and vomiting, with onset between 4 and 8 weeks' gestation, requiring in many cases frequent visits to the emergency room and sometimes repeated hospitalizations for intravenous hydration. Weight loss of at least 5 kg, ketonuria, abnormal liver function tests, and hypokalemia are common findings, depending on the severity of vomiting and dehydration. Free thyroxine levels are elevated, sometimes up to four to six times the normal values, whereas FT3 is elevated in up to 40 of affected women, values not as high as serum FT4. The T3 T4 ratio is less than 20, as compared with Graves' hyperthyroidism, where the ratio is over 20. Serum TSH concentrations are very low or suppressed.17 TPO antibodies are negative. In spite of the significant biochemical hyperthy-roidism, signs and symptoms of hypermetabolism are mild or...

Fetal hyperthyroidism

In mothers with a history of Graves' disease previously treated with ablation therapy, either surgery or 131I, concentrations of TSI may remain elevated, in spite of maternal euthyroidism. The concentration of these IgG immunoglobulins in the fetus reaches levels similar to the mother by 26-30 weeks gestation. Therefore, the symptoms of fetal hyperthyroidism are not evident until 22-24 weeks of gestation. Fetal hyperthyroidism is characterized by fetal tachycardia, IUGR, oligohydramnios, and a goiter may be identified on ultrasonography.28,32 The diagnosis may be confirmed by measuring thyroid hormone levels in cord blood obtained by cordocentesis.33 Treatment consisted of antithyroid medication given to the mother, PTU 100-400 mg day or methimazole 10-20 mg day. The dose is guided by the improvement and resolution of fetal tachycardia and normalization of fetal growth, both of which are indicators of good therapeutic response. Fetal ulreasonography in experts hands could be a...

Chronic autoimmune thyroiditis Hashimotos thyroiditis

Chronic autoimmune thyroid disease is more common in women with other autoimmune diseases, particularly Type 1 diabetes. The prevalence of positive TPO antibodies in women of childbearing age is between 3- and 5-fold higher in Type 1 diabetes.43 Figure 46.2 Evaluation of single thyroid nodules in pregnancy. (Adapted from Mestman JH. Thyroid and parathyroid diseases in pregnancy. In Obstetrics Normal and Problem Pregnancies, 5th ed. Gabbe SG, Niebyl JR, Simpson JL, eds. Elsevier Publishing, Philadelphia, PA 2007 (in print). Figure 46.2 Evaluation of single thyroid nodules in pregnancy. (Adapted from Mestman JH. Thyroid and parathyroid diseases in pregnancy. In Obstetrics Normal and Problem Pregnancies, 5th ed. Gabbe SG, Niebyl JR, Simpson JL, eds. Elsevier Publishing, Philadelphia, PA 2007 (in print). larger than the other, firm, rubbery consistency, and moving freely on swallowing. It is painless, although rapid growth of the gland may elicit some tenderness on palpation. Absence of...

Postpartum thyroid dysfunction

Thyroid dysfunction, hyper- and hypothyroidism, affects 5-10 of women in the 12 months following delivery, or following spontaneous or medically induced abortions.48 Most of the cases are due to intrinsic thyroid disease, with a few due to hypothalamic or pituitary lesions Patients with autoimmune thyroid disease, chronic thyroiditis, and Graves' disease are most frequently affected. The clinical diagnosis is not always obvious and the clinician should be concerned about nonspecific symptoms such as tiredness, fatigue, depression, palpitations, and irritability in women following the birth of their child or a miscarriage or abortion. Fatigue is the most common complaint. In some cases, the clinical symptoms resemble the syndrome of post-partum depression. Indeed, thyroid antibodies have been found more frequently in euthyroid women with postpartum depression, but this is still a controversial issue. Postpartum thyroiditis rarely develop in women with negative antibodies.47 In about...

4114 Thyroid hormones and thyroid receptor antibodies

L-thyroxine is used as a substitute in cases of hypothyroidism (at least 1 ng kg daily for adults), and, for this reason, is not problematic. The normal thyroid content of mother's milk is approximately 1 ng 1. An infant takes in about 0.15 ig kg in 24 hours this represents about 1 of a substitution dosage at this age (lOpg kg daily). This amount does not influence the thyroid function of a healthy infant. The same applies for treatment (substitution) of a maternal hypoparathyroidism. Thyroid receptor antibodies (TRAb) can result in transient neonatal thyroid disease by transfer through milk from mothers treated for thyrotoxicosis, Serum TRAb concentration in neonates decrease continuously with time after birth. The calculated half-life for offspring-serum and breast-milk TRAb was calculated as approximately 3 weeks and 2 months, respectively. Transient neonatal thyroid disease may be worse and more prolonged during breastfeeding as a consequence of TRAb in breast milk flomhage 2006)....

Hyperthyroidism overactive thyroid

There are many different causes of hyperthyroidism, but the most common by far is Grave's disease, which is associated with its own special set of antibodies (thyroid stimulating immunoglobulins, or TSIs) in the blood. These antibodies cause the thyroid to make too much thyroid hormone. Women with an overactive thyroid must receive adequate treatment during pregnancy (ideally, beginning before conception) in order to reduce their risk of such complications as miscarriage, preterm delivery, and low birth weight. If you have an overactive thyroid, unless your condition is extremely mild, your doctor is most likely to recommend that you take certain medications to lower the amount of thyroid hormone circulating in your blood. Some of these medications may cross the placenta, so your doctor watches the fetus closely, usually by performing regular sonograms, to look for any evidence that the medications are lowering the baby's thyroid levels too much. Specifically, she monitors the baby's...

Hypothyroidism underactive thyroid

A woman with an underactive thyroid (hypothyroidism) can have a healthy pregnancy as long as her condition is adequately treated. If it's not, she stands a higher risk of developing certain complications, such as a low birth-weight baby. The condition is treated with a thyroid replacement hormone (Synthroid, for example). This medication is safe for the baby because very little of it crosses the placenta. If you have an underactive thyroid, your doctor may want to periodically check your hormone levels to see whether your medication needs to be adjusted.

Congenital Hypothyroidism

Hypothyroidism occurs when the thyroid, a butterfly-shaped gland located in the front of the neck, cannot produce enough thyroid hormones. These hormones control the rate at which many of the body's chemical functions (metabolism) take place. Thyroid hormones are necessary for bone growth and critically important for normal brain development in infants and young children. roid gland usually occurs in infants with no known family history of the condition. Approximately 1 in 3,000 infants born in this country have the disorder. Some (nearly 10 percent) of these infants have a hereditary disorder affecting the ability of the thyroid gland to produce hormones, but most are born with absent or underdeveloped thyroid glands. The developing thyroid gland of the fetus can be damaged or destroyed, resulting in congenital hypothy-roidism, if the mother herself is treated with radioactive iodine for a thyroid condition during pregnancy. A temporary form of hypothyroidism can result if the mother...

Congenital Hypothyroidism In Infants

Facial Puffiness Hypothyroidism

Typical appearance of infant at the age of 9 days with congenital hypothyroidism (coarse facial features, puffiness of the eyelids, macroglossia, and coarse hair). Infant presented at birth with cardiogenic shock. Hospital course was remarkable for seizures and death at age 12 days from a pulmonary hemorrhage. Infant had a low T4 (thyroxine) and increased TSH (thyroid-stimulating hormone). Autopsy findings revealed the presence of inflammation involving the heart, brain, liver, and kidneys. The thyroid gland was normal histologically. Adenovirus was detected with poly-merase chain reaction (PCR) technology.

Single nodule of the thyroid gland

Nodular thyroid disease is clinically detectable in 10 of pregnant women. In most cases, it is discovered during the first routine clinical examination or detected by the patient herself. The chances for a single or solitary thyroid nodule to be malignant are between 5 and 10 , depending on risk factors such as previous radiation therapy to the upper body, rapid growth of a painless nodule, patient age, and family history of thyroid cancer. Papillary carcinoma accounts for almost 75-80 of malignant tumors, and follicular neoplasm for 15-20 a few percent are represented by medullary thyroid carcinoma. There is a paucity of information in the literature regarding the management and timing of the work-up in the presence of thyroid nodularity.40,41 It is generally agreed that elective surgery should be avoided in the first trimester and after 24 weeks' gestation because of the potential risks of spontaneous abortion and premature delivery, respectively. thyroid carcinoma. Fine-needle...

2157 Hyperthyroidism and thyrostatics

An uncontrolled hyperthyroidism of a pregnant woman is a risk for the outcome of pregnancy and the fetus fetal growth retardation, pre-eclampsia, prematurity, and intrauterine death or stillbirths occur more often (Glinoer 1997). In cases of Graves' disease or Hashimoto thyroiditis - the latter usually results in hypothyroidism - the maternal auto-antibodies should be tested at the beginning of pregnancy and early in the third trimester. A high concentration, especially of TSH-receptor antibodies (TRAb), is often correlated with a diaplacental transfer of these antibodies. It is estimated that 1-2 of pregnancies with Graves' disease result in a transient hyperthyroidism of the fetus or newborn, respectively (Carrol 2005). A recently published prospective study on 115 pregnant women reports a much higher rate of 12.6 of fetal neonatal hyperthyroidism (Rosenfeld 2005). Propylthiouracil has a higher protein-binding than the other thyrostatic substances, and presumably a lower placental...

Photo Of Baby With Hyperthyroidism

Vestigial Tail Deformity

This infant with congenital hyperthyroidism had a large midline neck mass due to a congenital goiter. Congenital goiter can occur when there is a defect in the synthesis of thyroid hormone (due to fetal TSH stimulation causing intrauterine growth of the thyroid gland) or in cases of maternal hyperthyroidism (due to long-acting thyroid stimulator LATS ) antibody crossing the placenta. Figure 5.13. This infant with congenital hyperthyroidism had a large midline neck mass due to a congenital goiter. Congenital goiter can occur when there is a defect in the synthesis of thyroid hormone (due to fetal TSH stimulation causing intrauterine growth of the thyroid gland) or in cases of maternal hyperthyroidism (due to long-acting thyroid stimulator LATS ) antibody crossing the placenta. Figure 5.14. This hyperactive, term male infant with transient congenital hyperthyroidism had severe growdi retardation. This infant's mother suffered from Graves' disease, and the maternal LATS...

Hyperthyroidism due to Graves disease

Which case the determination of FT3 or the FT3 index will confirm the diagnosis of hyperthyroidism. Thyroid peroxidase antibodies (anti-TPO) or thyroid antimicrosomal antibodies, are positive in the vast majority of patients. Significant maternal and perinatal morbidity and mortality were reported in early studies.19 In the last 20 years, however, there has been a significant decrease in the incidence of maternal and fetal complications directly related to improve control of maternal hyperthyroidism.16,18,20 The most common maternal complication is PIH. In women with uncontrolled hyper-thyroidism, the risk of severe preeclampsia was five times greater than in those patients with controlled disease.18 Other complications include preterm delivery, placental abruption, and miscarriage. Congestive heart failure may occur in women untreated or treated for a short period of time in the presence of PIH or operative delivery. Work up for thyroid dysfunction Single thyroid nodule Thyroid...

Neonatal hyperthyroidism

Neonatal hyperthyroidism is infrequent, with an incidence of less than 1 of infants born to mothers with Graves' disease, therefore affecting 1 in 50,000 neonates. The disease is caused by the placental transfer of stimulating thyroid antibodies (TSIs) from mother to fetus. High serum maternal TSI titers (a 3- to 5-fold increase over baseline), in the third trimester of pregnancy are predictors of neonatal hyperthyroidism.30 If the mother is treated with antithyroid medications, the fetus benefits from maternal therapy, remaining euthyroid during pregnancy. However, the protective effect of the antithyroid drug is lost after delivery, and neonatal hyperthyroidism may develop within a few days after birth. If neonatal hyperthyroidism is not recognized and treated properly, neonatal mortality may be as high as 30 . Since the half-life of the antibodies is only a few weeks, complete resolution of neonatal hyperthyroidism is the rule.28


The incidence of maternal hypothyroidism is between 0.19 and 2.5 .35 Subclinical hypothyroidism (normal FT4 and elevated TSH) is more often encountered than clinical hypothyroidism (low FT4 and elevated TSH). Mild elevations in serum TSH are frequently detected in hypothyroid women on thyroid replacement therapy soon after conception because of the increased demand for thyroid hormones in the first weeks of gestation.11 The two most common etiologies of primary hypothyroidism are autoimmune thyroiditis (Hashimoto's or chronic thyroiditis) and post-thyroid ablation therapy, surgical or 131I induced. Levothyroxine, or L-thyroxine, is the drug of choice for the treatment of hypothyroidism. In view of the complications mentioned above, it is important to normalize thyroid tests. An initial daily dose of 100-150 g of levothyroxine is well tolerated by the majority of young hypothyroid patients. In those with severe hypothyroidism, there is a delay in the normalization of serum TSH, but...

Northwestern Universitys Diabetes in Pregnancy Center Vehicle of the legacy

After making major, pioneering contributions to the understanding of thyroid hormone metabolism2-4 and to other areas of endocrinology early in his career, in the mid 1960s Norbert Freinkel turned his interests and talents to the study of intermediary metabolism in normal and diabetic pregnancy.4-7 By the early 1907s, he had established a Diabetes in Pregnancy Center (DPC) at Northwestern University and had attracted research collaborations globally. Over the next two decades, a virtual 'who's who' of the world's leading established and future investigators of intermediary metabolism in normal and diabetic pregnancy (basic and clinical) could be compiled from those that spent time as visiting scientists at the Northwestern University DPC. Several sources of objective support for this contention are cited below.

Endocrine Disorders During Pregnancy

In this issue, I have selected topics that cover each of the main subspecialties (adrenal, pituitary, diabetes, thyroid, and calcium bone) within adult endocrinology. For each area, the authors have delineated the current understanding of its physiology and pathophysiology during gestation as well as outlined the maternal therapy to optimize pregnancy outcome. In addition, I have included an article on the impact of polycystic ovarian syndrome on fertility, relevant because of its prevalence and the availability of therapy. Cardiovascular endocrinology, a newer subspecialty within our discipline, is well-represented by the article on pregnancy and hypertensive disorders. There are two other nontraditional articles. Recently, we have gained understanding of the effects of the intrauterine milieu on the future endocrine development of the child and this is presented in the section on imprinting. Lastly, the conclusion of pregnancy, parturition, represents a complex hormonal interplay...

Effect of other hormones on fetal glucose metabolism

Fetal thyroid hormone indirectly enhances fetal glucose utilization by increasing the fetal metabolic rate (oxygen consumption).51 Changes in fetal plasma cortisol concentrations during late gestation have little effect on fetal glucose concentrations or on the rates of glucose utilization.52 However, fetal plasma cortisol concentrations do increase in very late gestation, at which time cortisol-dependent increases in fetal hepatic glycogenolytic and gluconeogenic enzyme activities develop. These may enhance the glucogenic capacity of the fetus, thereby contributing to the endogenous glucose production observed in normal fetuses just before term and at the time of delivery.53 Glucagon and circulating catecholamines (adrenal epinephrine and spillover norepinephrine from peripheral nerve endings) are normally present in modest concentrations in the fetal plasma, but they do stimulate fetal glucogenesis when infused into the fetus. Catecholamines promote glucose production at...

Fetal Risk Summary

A group of 20 women in premature labor, treated with oral albuterol (4 mg every 4 hours for several weeks), was matched with a control group of women who were not in premature labor (36). The mean gestational ages at delivery for the treated and nontreated patients were 36.4 and 37.0 weeks, respectively. No significant differences were found between the groups for cord blood concentrations of insulin, triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH). However, growth hormone levels were significantly higher in the treated group than in control patients (36.5 vs. 17.4 ng mL, respectively, p

Autoimmune gestational diabetes as a clinical entity

DM-1 is considered an autoimmune disorder progressing toward the selective destruction of the beta cells. Subjects with DM-1 frequently display evidence of autoimmune disorders specific to other organs thyroid, adrenal cortex, gastric mucosa, and antigliadin antibodies in childhood. Autoimmune destruction of the beta cells is determined by multiple genetic susceptibility and modulated by undefined environmental factors. The autoimmune response may be detected for months or years before the clinical onset. Patients with Type 1 diabetes have an increased risk of other autoimmune disorders, including Graves disease, thyroiditis, Addison disease, celiac disease, and pernicious anemia. A minority of patients with Type 1 diabetes have no known

13 The Differential Diagnosis

In addition, organic causes such as thyroid dysfunction must be ruled out. Approximately 5 of all postpartum women (11) and 50 of the 10 of women who have thyroid peroxidase antibodies during early gestation develop thyroid dysfunction during the first 9 mo after delivery (12,13). One-third of these women will develop permanent hypothyroidism (14), and findings from several studies suggest that women who are thyroid peroxidase antibody-positive during early gestation are at increased risk of PPD regardless of postpartum thyroid function (15-18).

Prevalence of Mood and Anxiety Disorders During Pregnancy

Anemia, gestational diabetes, and thyroid dysfunction, may be associated with depressive symptoms and may complicate the diagnosis of depression during pregnancy (Klein and Essex 1995). Clinical features that may support the diagnosis of major depression during pregnancy include anhedonia, feelings of guilt and hopelessness, and suicidal thoughts. Suicidal ideation is not uncommon among depressed pregnant women however, risk of self-injurious or suicidal behaviors appears to be relatively low in women who develop depression during pregnancy (Appleby 1991 Frautschi et al. 1994 Marzuk et al. 1997).

2 Biological Underpinnings Of Postpartum Mood Disorders

Why me Why now are questions commonly asked by women suffering from postpartum mental illness, particularly those who have never previously experienced a serious psychiatric disturbance. Although according to the DSM-IV, PPD is not diagnostically distinct from MDD that is not childbirth-related (24), the hormonal milieu of pregnancy and the puerperium is so unique that investigators have focused on these hormonal changes as key factors in the pathogenesis of PPD. Several recent and thorough reviews of the relationship between PPD and endocrine function have been published (18,43). Tables 3-6 provide an overview of the findings from studies focused primarily on the relationship between ovarian, adrenal, and thyroid hormones and postpartum mood disorders. Thyroid Hormones and -Endorphins in the Pathogenesis of Postpartum Depression (PPD) or Psychosis Thyroid Hormones and -Endorphins in the Pathogenesis of Postpartum Depression (PPD) or Psychosis No difference in thyroid hormone levels...

Primary adrenal insufficiency in pregnancy

Isolated autoimmune adrenalitis is the most common cause of primary AI in developed countries. Although the glands are small in autoimmune primary adrenal disease, they are large in tuberculous or fungal infection, bilateral metastases, hemorrhage, or infarction. Less common causes of AI, autoimmune polyglandular syndrome type 2 (APS-2) and Schmidt's syndrome (primary autoimmune hypoadrenalism, type 1 diabetes mellitus, thyroid autoimmune disease), were reported in at least seven pregnancies 27 . In APS-2, the appropriate management of hypothyroidism and diabetes during gestation poses a particular challenge beyond that of isolated hy-poadrenalism 27 .

Pregestational diabetes

A complete anamnesis is imperative before planning for pregnancy. This should include, but not be limited to, questioning for duration and type of diabetes (Type 1 or Type 2), acute complications, including history of infections, ketoaci-dosis, and hypoglycemia, chronic complications, including retinopathy, nephropathy, hypertension, atherosclerotic vascular disease, and autonomic and peripheral neuropathy, diabetes management, including insulin regimen, prior or current use of oral glucose-lowering agents, SMBG regimens and results, medical nutrition therapy, and physical activity, concomitant medical conditions and medications, thyroid disease in particular for patients with Type 1 diabetes, menstrual pregnancy history contraceptive use and support system, including family and work environment.70 To minimize the occurrence of malformations, standard care for all women with diabetes who have child-bearing potential should include Measurement of serum thyroid stimulating hormone and...

Explanation Of Condition

Addison's disease refers to primary adrenal insufficiency. Of all cases, 70-90 are due to autoimmune destruction of the adrenal cortex (either alone or associated with other organ-specific autoimmune conditions, e.g. type 1 diabetes, autoimmune thyroid disease). Of the remainder, most cases are due to tuberculosis. Autoantibodies to the enzyme 21-hydroxylase are often present in autoimmune Addison's disease.

21110 Lithium and other moodstabilizers antimanic agents

Some authors recommend controlling thyroid function in both the pregnant woman and the neonate (Frassetto 2002. Llewellyn 1998). Recommendation. Exposure to lithium is not an indication for termination of pregnancy. Women who need lithium therapy may continue the drug during pregnancy, but they should be closely monitored. Lithium should be given in small, divided doses (i.e. slow-release preparations). Monthly monitoring of maternal serum levels of lithium is recommended, weekly during the last month of pregnancy, and every 2 days perinatally. If necessary, the dose should be adjusted. Salt-restricted diets and diuretics should be avoided. A detailed fetal echocardiography should be offered. Ultrasound monitoring may control for polyhydramnios. Lithium should be decreased or discontinued when delivery is expected, and reinstituted immediately after delivery. The thyroid function in both the pregnant woman and the neonate should be controlled, as well as toxic symptoms in the neonate....

6 Bipolar Disorder And The Postpartum Period

The pathophysiology of bipolar exacerbation during the postpartum period is not understood. Proposed contributors to the destabilization of mood include disturbances in the hypothalamic-pituitary-thyroid axis and major withdrawal of steroid hormones after birth (112-115). The changes in reproductive hormone status are considered important in regulating mood, and rapid and steep decline in estrogen after delivery may trigger mood changes in vulnerable women regardless of their diagnosis (110,116). The efficacy of hormone replacement therapy for bipolar disorder during the postpartum period has not been adequately assessed (112,113).

2151 Hypothalamic releasing hormones

Synthetic analogs are protirelir( l) corticorelii lJiH controls thyroid function via the thyroid-stimulating hormone (TSH), and also stimulates prolactin secretion. There is evidence that TRH exerts a significant relaxant effect in human myometrium and in human umbilical vasculature. These effects could have clinical implications in treated pregnant women (Potter 2004). Some authors have suggested that TRH added to prenatal glucocorticoids in women at risk of preterm delivery could reduce pulmonary problems and neonatal lung disease. Nevertheless, some studies and an extensive review of the literature published on this topic, with over 4600 women analyzed, concluded that prenatal TRH in addition to corticosteroids did not reduce the risk of neonatal respiratory diseases, but can produce adverse effects in both women and their infants (Crowther 2004, 1997, Ballard 1998). Some authors described an association between maternal treatment with TRH and delay in mental development in...

Breast Feedinq Summary

A 1984 article discussed the potential benefits of combining thyroid hormones with corticosteroids to produce an additive or synergistic effect on fetal lung phosphatidylcholine synthesis (38). The therapy may offer advantages over corticosteroid therapy alone, but it is presently not possible because of the lack of commercially available thyroid stimulators that cross the placenta. The thyroid hormones, T4 and T3, are poorly transported across the placenta and thus would not be effective.

2173 Antiseptics and disinfectants

When povidone iodine is used as a local disinfectant on intact skin, on wounds and on the mucosa as well as in body cavities, iodine transfer to the fetus must be assumed. This can lead to functional disturbances in the fetal thyroid gland. The intake of iodine from a vaginal douche during labor can lead to a temporary TSH-increase in the newborn's blood - a sign of transient hypothyroidism (Weber 1998). This should be considered in the interest of the undisturbed thyroid status necessary for central nervous system differentiation. Retrospective evaluation of children born to mothers who applied iodine vaginal douching did not show indications of teratogenic effects (Czeizel 2004). However, this study did not identify the time of exposure or usage during pregnancy.

Checking In Babys First Doctor Visit

When the pediatrician examines your baby, he checks the baby's general appearance, listens for heart murmurs, feels the fontanelles (the openings in the baby's skull where the various bones come together), looks at the extremities, checks the hips, and generally makes sure that the baby is in good condition. The pediatrician orders a variety of standard blood tests and newborn screening tests. The specific screens that are required vary from state to state but often include tests for thyroid disease, PKU (a condition in which a person has trouble metabolizing some amino acids), and other inherited metabolic disorders. The results of these screening tests usually don't come back until after you take your baby home. The pediatrician gives you the results at your baby's first office visit. If any of the tests come back positive, the state also notifies you by mail. Be sure to ask the pediatrician upon discharge when your baby should be seen again.

Mary Frances Picciano and Michelle Kay McGuire

Summary National surveys indicate that as many as 97 of women living in the United States are advised by their health care providers to take multivitamin, multimineral (MVMM) supplements during pregnancy, and 7-36 of pregnant women use botanical supplements during this time. Although there is evidence of benefit from some of these preparations, efficacy has not been established for most of them. This chapter reviews some of the most commonly used prenatal supplements in terms of the evidence for their need, efficacy, and safety. Specifically, MVMM, folate, vitamin B6, vitamin A, vitamin D, iron, zinc, magnesium, and iodine are discussed, as are several botanicals. Data indicate that, in general, evidence for benefit gained from taking prenatal MVMM supplements is not well established except for women who smoke, abuse alcohol or drugs, are anemic, or have poor quality diets. Because of folate's well-established effect on decreasing risk for neural tube defects, it is recommended that...

1432 Evidence that MVMM Supplementation during Pregnancy is Beneficial

ANote that this supplement formulation was suggested prior to the establishment of (1) the DRI values, (2) the American Thyroid Association recommendation that all pregnant women receive iodine supplements (150 mcg day), and (3) the current recommendation that all women of childbearing age consume 0.4 mg day (400mcg day) folic acid in the form of supplements or fortified foods aNote that this supplement formulation was suggested prior to the establishment of (1) the DRI values, (2) the American Thyroid Association recommendation that all pregnant women receive iodine supplements (150 mcg day), and (3) the current recommendation that all women of childbearing age consume 0.4 mg day (400mcg day) folic acid in the form of supplements or fortified foods

2201 Xray examinations

These effects are a function of the dose administered and of the stage of development of the embryo. Embryo fetai death may also occur during the first 5 days after conception (i.e. in the all-or-none period ) the lowest lethal dose is 10 rads (0.1 Gy). During embryogenesis, the lowest lethal dose for the embryo increases to 25-50 rads and later to more than 100 rads (lGy) (Brent 1999). Severe CNS malformations are to be expected with exposures above 20 rads during early gestation (18-36 days after conception). Microcephaly and mental retardation were observed only after exposures above 20 rads between weeks 8 and 15 after conception. The conclusion from most studies is that for doses lower than 0.05 Gy (i.e. 5 rads) there is no significant increase of the malformation rate in humans, and the risk clearly is increased above 20-50 rads (Brent 1999. Sternberg 1973). A common and important finding is the absence of visceral, limb or other malformations unless there is...

2205 Iodinecontaining contrast media

The amount of free iodine in the contrast medium is less than 0.1 of the total. The amount of the free iodide depends on the compound, and can increase during storage. The Contrast Media Safety Committee of the European Society of Urogenital Radiology reviewed the literature and developed guidelines (Webb 2005). Free iodide can reach the fetal thyroid and be stored there. The danger with iodine in excess is transient fetal hypothyroidism, particularly from the twelfth week of pregnancy onward, when the fetal thyroid starts its endocrine function (Webb 2005). Recommendation. In particular during the second and third trimesters, iodine-containing contrast agents should only be used for compelling diagnostic indications. Neonatal thyroid function should be checked carefully during the first week.

2207 Radioactive isotopes

In contrast, when radioactive isotopes (mainly the radioiodine I131) are used as therapeutics, as in hyperthyroidism or thyroid carcinoma, doses may be above 100 mCi (millicuric), and this can induce fetal hypothyroidism or even athyroidism (Bcntur 1991). According to larger studies covering in total several hundred women exposed to I131 for thyroid carcinoma or hyperthyroidism before becoming pregnant, the results have revealed no evidence that exposure to radioiodine affects the outcome of subsequent pregnancies and offspring (Bal 2005, Chow 2004, Read 2004, Schlumberger 1996). Several children were observed until adulthood without indications for an increased risk of carcinogenesis or mutagenic insults. The observed increase of miscarriages in those women who were treated within 1 year before the index pregnancy could be related to gonadal irradiation or to insufficient control of the hormonal thyroid status (Schlumberger 1996). Read (2004) found no birth defects among 36 infants...

Prepregnancy counseling

The physician may be faced with different clinical situations when counseling a woman with thyroid disease contemplating pregnancy. Hyperthyroidism on antithyroid drug treatment If the woman decides to continue antithyroid drug therapy, PTU is the drug of choice in view of rare cases of methimazole embri-opathy (see section on hyperthyroidism). She should be made aware of the importance of frequent testing during gestation to achieve target serum thyroxine levels and the potential side effects on the fetus. Alternative therapies, 131I ablation or thyroidectomy should be discussed. If the patient opts for ablation therapy, there is no long-term effect of 131I therapy on the offspring. However, it is customary to wait 6 months after the therapeutic dose is administered before pregnancy is contemplated. Regardless of the form of therapy chosen, it is important for the patient to be euthyroid at the time of conception.

Previous ablation treatment for Graves disease

Women treated with ablation therapy and on thyroid replacement therapy will need to increase levothyroxine doses soon after conception to avoid hypothyroidism.11 In spite of remaining euthyroid on replacement hormonal therapy, in a subgroup of patients, high maternal titers for TSI or TSHRAb may be present, with the fetus being at risk of developing hyperthy-roidism despite the mother being euthyroid (Box 46.1). Close follow-up during pregnancy and communication between the obstetrician and endocrinologist is essential.

Maternalplacentalfetal interactions

Studies in the last two decades have shown an important role of maternal thyroid hormones in embryogenesis.14 Maternal thyroxine crosses the placenta in the first half of pregnancy at the time when the fetal thyroid gland is not functional. Maternal TSH does not cross the placenta. TRH does cross the placental barrier, but its physiologic significance is unknown. Methimazole (MM) and propylthiouracil (PTU), cross the placenta, and if given in inappropriate doses may produce fetal goiter and hypothyroidism.15

Universal screening vs casefinding cases

Universal vs. case-finding case screening for thyroid disease in pregnancy is controversial.46 Those women at risk (Box 46.2) should be screened before or early in pregnancy, with the determination of serum TSH and TPOAb. If the serum TSH is elevated a free thyroxine tests should be added. In a recent publication, 40 women out of 1560 consecutive pregnant women (2.6 ) had an elevated serum TSH, and 70 of them were in the high-risk group, while 30 of them had no risk factors based on medical history. This study along with a previous one7 appears to support universal thyroid screening early in pregnancy.

22310 Radiation associated with the nuclear industry

Although not apparent for the first 3 years after the accident, by the end of 1994 a clear increase in childhood thyroid cancers was being seen in children from the surrounding areas. As the data available so far cover only approximately 10 years since the incident. it is too early for there to be significant information concerning other cancers. No relevant data were found regarding whether there was any change in the incidence of reproductive toxicity or in the incidence of congenital anomalies in the surrounding areas.

Impact of Reproductive Hormones on Risk of Illness

The postpartum period is characterized by a rapid shift in the hormonal environment. Within the first 48 hours after delivery, estrogen and progesterone concentrations fall dramatically. Because these gonadal steroids modulate neurotransmitter systems implicated in the pathogenesis of mood disorders, many investigators have proposed a role for these hormones in the emergence of affective illness during the postpartum period. However, there appears to be no consistent correlation between serum levels of estrogen, progesterone, cortisol, or thyroid hormones and the occurrence of postpartum mood disturbance (Hendrick et al. 1998 Wisner and Stowe 1997). Although previous studies indicate that serum levels of gonadal steroids or other hormones may not be useful in identifying women at highest risk for postpartum psychiatric illness, these findings do not exclude a role for reproductive hormones in the etiology of postpartum mood disorders. It has been hypothesized that a subgroup of women...

Endocrine and Metabolic Disorders

Endocrine and metabolic processes are actively involved in the growth and development of the fetus from conception. Clinical disorders of endocrine and metabolic function in the neonate are most often based upon abnormal physiologic function in either the fetus or mother during gestation. The timing of these disturbances during gestation can result in varying clinical presentations. Endocrine system involvement may include the thyroid, pituitary, hypothalamus, parathyroid, testes, ovaries, and adrenal glands. Metabolic disorders may include carbohydrate, amino acid, fatty acid, calcium, phosphorus, and magnesium metabolism. Advances in the recognition, treatment and prevention of many endocrine and metabolic disorders make it imperative that the clinician be familiar with these disorders. Although screening programs exist for many of these disorders, many children remain undiagnosed. Clinicians must remain aware of these conditions so that infants may be diagnosed early and the...

4126 Vaginal therapeutics

Are used as antiseptics or antimicrobials. Iodine is absorbed via the skin and mucous membranes and moves into milk via a positive pump, so milk levels far exceed maternal plasma levels (see Chapter 4.11). A high intake of iodine suppresses the infant's thyroid activity.

Fissure Of The Nipple

Branchial Sinuses And Cysts

Another example of a congenital midline cervical cleft. Note the characteristic nipple-like projection, atrophic skin defect, and caudal fistulous tract. This may become a fibrous cord and result in a web-like contracture. This must be differentiated from a thyroglossal duct cyst sinus which develops if the thy-roglossal duct fails to close after the descent of the thyroid gland into the lower neck. It can occur anywhere on a line connecting the sternal notch and the base of the tongue. Figure 1.160. Another example of a congenital midline cervical cleft. Note the characteristic nipple-like projection, atrophic skin defect, and caudal fistulous tract. This may become a fibrous cord and result in a web-like contracture. This must be differentiated from a thyroglossal duct cyst sinus which develops if the thy-roglossal duct fails to close after the descent of the thyroid gland into the lower neck. It can occur anywhere on a line connecting the sternal notch and the base of...

Rabin Medical Center Petah Tiqva Israel

This major book gives a comprehensive review of the epidemiology, science and clinical management of gestation diabetes. Fully updated and revised, it contains new chapters on Fetal growth in normal and diabetic pregnancies Genetics Congenital anomalies Exercise Pharmacological management Insulin pump therapy Hypoglycemia The role of ultrasound for timing of delivery Thyroid and pregnancy Fetal origins of adult disease Metabolic syndrome and diabetes following gestational diabetes mellitus Psychological and social aspects

Psychotherapeutic and Pharmacotherapeutic Interventions

Depression, characterized by prominent neurovegetative symptoms and marked impairment of functioning. Treatment should be guided by the type and severity of the symptoms and the degree of functional impairment. However, before initiation of psychiatric treatment, medical causes of mood disturbance (e.g., thyroid dysfunction, anemia) must be excluded. Initial evaluation should include a thorough history, physical examination, and routine laboratory tests.

Respiratory Disorders

Girling JC 2003 Thyroid disorders in pregnancy. Current Obstetrics and Gynaecology, 13 45-51 5. Hershman JM 2002 Thyroid disease during pregnancy in Wass JAM and Shalet SM (Eds) Oxford Textbook of Endocrinology and Diabetes. Oxford Oxford University Press 522-524 2. Girling JC 2003 Thyroid disorders in pregnancy. Current Obstetrics and Gynaecology, 13 45-51 4. Hershman JM 2002 Thyroid disease during pregnancy in Wass JAM and Shalet SM (Eds) Oxford Textbook of Endocrinology and Diabetes. Oxford Oxford University Press 522-524

Clinical Aspects of Trisomy 21 Down Syndrome

Before the advent of antibiotics, the survival of Down syndrome infants was relatively poor. The life expectancy was only 12 yr in 1947 (73), but the current use of antibiotics and cardiac surgery to repair congenital cardiac anomalies has helped to increase life expectancy. Of those surviving the first 5 yr of life, 85 will have a life expectancy of at least 30 yr with many living to age 50 (74,75). There are medical problems throughout life, including immunodeficiency disorders, thyroid dysfunction, Alzheimer-like disorders, and a substantially increased risk of leukemia.

Conception During Breast Feeding References

In 22 cases of amiodarone therapy during pregnancy, the antiarrhythmic was administered for maternal indications (1,2 and 3,5,7,8 and 9,11,12,13,14,15 and 16). One patient in the last 3 months of pregnancy was treated with 200 mg daily for resistant atrial tachycardia (1). She delivered a 2,780-g female infant at 40 weeks' gestation. Both the mother and the infant had a prolonged QT interval on electrocardiogram (ECG). A second woman was also treated by these investigators under similar conditions. Both infants were normal (infant sex, weight, and gestational age were not specified for the second case), including having normal thyroid function. In another report, a woman was treated at 34 weeks' gestation when quinidine failed to control her atrial fibrillation (2). After an initial dose of 800 mg day for 1 week, the dose was decreased to 400 mg day and continued at this level until delivery at 41 weeks' gestation. The healthy 3220-g infant experienced bradycardia during labor...

2133 Vinca alkaloids and structural analogs

Knowledge regarding the treatment of pregnant women with cyclophosphamide during the first trimester is based on a small cases series (Aviles 1991) and retrospective case reports. In total, there are reports on more than 30 women treated during the first trimester, including one twin pregnancy 17 children were healthy or without congenital malformations (Fernandez 2006, Peres 2001, Aviles 1991, Pizzuto 1980), 11 fetuses and children had major or minor malformations (Paskulin 2005, Paladini 2004, Vaux 2003, Giannakopoulou 2000, Enns 1999, Mutchinick 1992, Kirshon 1988, Murray 1984, Toledo 1971, Greenberg 1964), two pregnancies ended in spontaneous miscarriage (Clowse 2005), and in two other pregnancies the fetuses died in weeks 25 26 (Peres 2001. Ba-Thike 1990). Furthermore, a boy who was born with multiple malformations developed thyroid cancer at 11 years of age and a neuroblastoma at age 14 at the age of 16 a metastasizing papillary thyroid carcinoma was diagnosed. His twin sister...

The Chinese viewpoint

In Chinese medicine there is no discourse on the immune system as such. However, according to Professor Yu Jin of Shanghai Medical University, 'The Kidneys are said to be the essence of life, while the Liver has a common source with the Kidneys. Both relate to growth and reproduction, and can thus be associated with the functions of the hypothalamus, pituitary, ovaries, adrenals, and thyroid, which also comprise the body's immuno-neuroendocrine framework' (Yu Jin 1998).

123 Minerals

Iodine needs increase during pregnancy for the synthesis of thyroid hormones. Maternal iodine deficiency during pregnancy can result in the enlargement of a woman's thyroid gland, development of goiter, and hypothyroidism. Maternal hypothyroidism increases the risk of a variety of poor fetal outcomes including stillbirth, spontaneous abortion, congenital anomalies, mental retardation, deafness, spastic dysplegia, and cretinism 3 . To avoid risk of harm to the fetus, maternal iodine deficiency should be corrected prior to conception. During gestation, fetal iodine deposition is approximately 75 mcg day. Results from iodine balance studies as well as iodine supplementation trials to prevent thyroid enlargement and goiter during pregnancy corroborate that an additional 70 mcg day is required to cover the pregnancy needs of 97-98 of the population during pregnancy 20 .

Of North America

Adult endocrinologic disorders during pregnancy are discussed in this issue and include pituitary, adrenal, thyroid and calcium disorders. Drs. Mandel and LeBeau discuss thyroid disorders in pregnancy, covering the effect of pregnancy on thyroid function and thyroid hormone measurements. Conversely, thyroid metabolism affects pregnancy, and thyroid disorders in pregnancy need particular care due to the effects on the pregnancy, the fetus, and the newborn.

Unipolar Depression

Tational diabetes, and thyroid dysfunction, may be associated with depressive symptoms and may complicate the diagnosis of depression during pregnancy. Clinical features that may support the diagnosis of major depression include anhedonia, feelings of guilt and hopelessness, and suicidal thoughts. Suicidal ideation is often reported however, risk of self-injurious or suicidal behaviors appears to be relatively low in the population of women who develop depression during pregnancy (Appleby 1991 O'Hara et al. 1984).

Interassay Variation

Nicked Hcg

In all 54 confirmed false-positive cases, there was no prior history of trophoblastic disease or other tumors. Patients were treated for a diagnosis of ectopic pregnancy, gestational trophoblastic disease, or choriocarcinoma. Each case started with an incidental pregnancy test. Forty-five of 54 received needless surgery or single-agent chemotherapy many received an unnecessary hysterectomy or other major surgery, or cytotoxic combination chemotherapy (32-38). To the best of our knowledge, in all cases, after false-positive hCG was identified, all treatment was halted, even though the quantitative test remained positive. Women having false-positive hCG results may also have falsely elevated results in other unrelated tests such as CEA, CA125, PSA, thyroid hormones, troponin, and other tumor and cardiac markers (39).


Investigation consists of the measurement of circulating thyroid hormones with thyroid function tests. In primary hypothyroidism thyroid stimulating hormone (TSH) will be raised, free thyroxine (fT4) will be reduced, as will fT3, although this is not always measured. In central hypothy-roidism the TSH will also be low. TPO antibodies are usually positive in autoimmune thyroiditis. Up to 5 of women have positive antibodies in early pregnancy.


Graves' disease Most women with primary hyperthyroidism in pregnancy will have Graves' disease (GD), an autoimmune condition in which thyrotoxicosis is caused by auto-antibodies to the thyroid stimulating hormone receptor (TSHR). These thyroid stimulating immunoglobulins (TSIg) mimic the effects of TSH on its receptor, but in an unregulated way. Endogenous TSH falls in response to high levels of fT3 and fT4, but production and release of these hormones continues to be stimulated by TSIgs. A smooth, symmetrical goitre (enlarged thyroid gland) is often present, over which a bruit may be heard. In some cases Graves' disease is associated with other organ-specific autoimmune conditions, e.g. type 1 diabetes and pernicious anaemia. Excess thyroid hormone ingestion This may be iatrogenic (overtreatment of hypothyroidism) or factitious (taking thyroid hormone surreptitiously, perhaps to aid weight loss).

Brain Food

Choline and iodine are also critical for brain development at this stage. Choline is needed for the manufacture of cell membranes and for cell division is used by nerve cells and, according to animal studies, is linked to the memory and learning centers of the br ain. A balanced diet will usually deliver enough choline. Brain development will be stunted in the first trimester if the maternal supply of thyroid hormone is insufficient, and iodine is important for synthesis of this hormone (see pages 1 34 6 for sources of essential fats, choline, and iodine).


Severe maternal iodine deficiency during pregnancy has long been known to increase risks for stillbirths, abortions, and congenital abnormalities 104 . In its more serious condition, prenatal iodine deficiency causes cretinism, which is characterized by stunting, difficulty in hearing and speaking, and sometimes-profound mental retardation 105 . In fact, iodine deficiency is considered the world's most frequent cause of preventable mental retardation. In addition to detrimental effects of iodine deficiency on infants and children, maternal postpartum thyroid dysfunction is relatively common and related to chronic iodine deficiency as well 106 . The complications of both maternal and infant iodine defi-ciency collectively known as iodine deficiency disorders are complex, and the etiology of these deficiency characteristics is owed to iodine's critical role as a component of the quaternary structures of the thyroid hormones thyroxine (T4) and triiodothyronine (T3). In response to these...

4115 Thyrostatics

With 5 mg thiamazol per day, up to 65 ig 1 milk could be measured. Accordingly, an infant would receive up to 9.8pg kg daily. This represents about 12 of the maternal dosage per kg bodyweight. In the plasma of breastfed twins, 45 and 53 ig l - subtherapeutic levels - of thiamazol were found. The children had no symptoms, and their thyroid status was unremarkable (Rylance 1987). With treatment using 400 mg propylthiouracil, a maximum of 0.7 mg l was found in the mother's milk. For the infant this is at most 0.1 mg kg, i.e. 1.5 of the maternal weight-related dosage in 24 hours. The M P ratio is 0.1 (Kampmann 1980), In older studies in which the methodology was insufficient, M P values of 12 were calculated. In a newer study of 11 children whose mothers took 300-750 mg daily, elevated TSH values were seen in 2 children 7 days after birth. However, these normalized over the course of time, although the maternal dosage remained stable or was even increased. No correlation was found between...

4143 Radionuclides

Iodine131 (,5II) accuinulatcs in mother's milk at the same levels as normal iodine (see Chapter 4.11). Among 31 radionuclides studied for their appearance in mother's milk, 13II had the highest transfer (with 30 of the maternal dose), followed by 45Ca and lJ Cs (both 20 ) and *JSr (10 ) (Harrison 2003). In their review on 131I, Simon and co-workers (2002) found a median half-life in milk of 12 hours. When the mother received stable iodine to block her thyroid before administration of1311, he median half-life was 8.5 hours. Peak values were measured after 9 hours. Stable iodine blocks also the 1311 uptake of the breast and the infant's thyroid. In 1996, Bennett summarized the kinetics of many radiopharmaceuticals during breastfeeding, among them iodine and technetium isotopes. It is difficult to decide what dosage of radioactivity is tolerable for the breastfed Infant most authors accept 1 mSv, In the context of the radioiodine contamination after Chernobyl, the German Radiation...


Radioiodine (131I) can cause fetal hypothyroidism (298), is considered a category X drug, and is contraindicated in pregnancy. Uptake is minimal before 12 weeks of gestation (299), however. Sodium iodide delivers less than 10 mrad to the fetal thyroid, and its uptake into the fetal thyroid may be blocked by administering stable iodide to the mother, making administration during pregnancy feasible.

Erectile dysfunction

Diabetic men have a higher prevalence of erectile dysfunction (ED) than nondiabetic men. Erectile function is primarily a vascular phenomenon, triggered by neurologic controls and facilitated by appropriate hormonal and psychological components. All of these factors are affected by diabetes. Recent advances in the understanding of the physiology of penile vas-culature and its role in male sexual performance have influenced the clinical approach to ED. A thorough history and physical examination are an important aspect of ED management. It is also important to rule out secondary causes such as hypogonadism and thyroid abnormalities.125

Hormonal Influences

A programmed transformation of the mammary epithelium mediated by a cascade of hormonal changes leads to a rapid synthesis of breastmilk by day 4 following birth. The postpar-tum period is characterized hormonally by a drop in progesterone and elevated levels of prolactin, which act synergistically with cortisol, thyroid-stimulating hormone, prolactin-inhibiting factor, and oxytocin to establish and maintain lactation. If the delicate interplay of these hormones are dis-turbed for example, by high testosterone levels in the woman with theca lutein cysts (Hoover, Bar-balinardo, & Pia Platia, 2002) or polycystic ovary syndrome (Marasco, Marmet, & Shell, 2000), lacto-genesis is delayed and possibly suppressed (see Chapter 16).

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