Effects of the Menstrual Cycle on Medical Disorders

REVIEW ARTICLE Effects of the Menstrual Cycle on Medical Disorders

Allison M. Case, MD; Robert L. Reid, MD

xacerbation of certain medical conditions at specific phases of the menstrual cycle is a well-recognized phenomenon. We review the effects of the menstrual cycle on medical conditions, including menstrual migraine, epilepsy, asthma, rheumatoid arthritis, irritable bowel syndrome, and diabetes. We discuss the role of medical suppression of ovulationE using gonadotropin-releasing hormone agonists in the evaluation and treatment of these disorders. Peer-reviewed publications from English-language literature were located via MEDLINE or from bibliographies of relevant articles. We reviewed all review articles, case reports and series, and therapeutic trials. Emphasis was placed on diagnosis and therapy of menstrual cycle– related exacerbations of disease processes. Abrupt changes in the concentrations of circulating ovarian steroids at ovulation and premenstrually may account for menstrual cycle–related changes in these chronic conditions. Accurate documentation of symptoms on a menstrual calendar allows identification of women with cyclic alterations in disease activity. Medical suppression of ovulation using gonadotropin-releasing hormone agonists can be useful for both diagnosis and treatment of any severe, recurrent menstrual cycle–related disease exacerbations. Arch Intern Med. 1998;158:1405-1412

The menstrual cycle, an event that punctu- Several theories have been proposed to ates the lives of most women, may be asso- explain these menstrual cycle–related effects ciated with diverse physical, psychological, on existing disease processes, including fluc- and behavioral changes. Not surprisingly, it tuations in levels of sex steroids, cyclic alter- plays a significant role in women’s health and ations in the immune system, and changing disease. Conversely, menstrual cyclicity can perceptionsofdiseaseseveritybroughtabout be easily disrupted by disease, both physi- by premenstrual alterations in mood, as seen cal and psychological. in premenstrual syndrome. Exacerbation of certain medical conditions at specific menstrual cycle phases THE MENSTRUAL CYCLE is a well-recognized phenomenon. Accu- rate documentation of symptoms on a men- Normal menstrual cyclicity requires coordi- strual calendar allows identification of nation of the hypothalamus, pituitary gland, women with cyclic alterations in disease ac- and ovaries. Gonadotropin-releasing hor- tivity. The majority of these effects occur mone is released in a pulsatile fashion from during the luteal and menstrual phases of thehypothalamus.Itssecretionismodulated the cycle. Diseases most often affected are by a variety of neurotransmitters, including those characterized by relapsing and re- norepinephrine, serotonin, and endogenous mitting courses, and those that are easily opioids. Gonadotropin-releasing hormone triggered by external factors; for example, migraine, asthma, and epilepsy. This article is also available on our Web site: www.ama-assn.org/internal. From the Department of Obstetrics and Gynaecology, Queen’s University, Kingston General Hospital, Kingston, Ontario.

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Downloaded From: https://jamanetwork.com/ on 09/23/2021 stimulates the release of follicle-stim- “add-back” therapy, similar to post- exist in prepubertal children.6,7 The ulating hormone and luteinizing hor- menopausal hormone replacement frequency of migraine headaches in mone from the anterior pituitary.1 therapy. Patients receiving gonado- women increases considerably af- The follicular phase, or the time tropin-releasing hormone agonists ter menarche.8-10 Sixty percent of of oocyte development before ovu- take a small dose of estrogen daily women with migraine link attacks lation, is marked by progressive (0.625-1.25 mg of conjugated estro- to menstruation. True menstrual mi- growth of an ovarian follicle. This gens or 1-2 mg estradiol). A proges- graine, however, occurs in the 8% to phase is characterized by estrogen se- tational agent (5 mg of medroxypro- 14% of women who experience mi- cretion, at first gradual, and then ex- gesterone acetate or 200 mg of oral graines exclusively at the time of ponential in the 5 to 6 days leading micronized progesterone) is admin- menstruation, and are virtually free up to ovulation. An abrupt transient istered on a cyclic schedule for 12 to of migraine at other times of the decline in estrogen level occurs co- 14 days every 1 to 3 months to in- cycle, with the exception of the small incident with ovulation. Recovery in duce a withdrawal bleed and mini- percentage of these women who ex- the luteal phase results from corpus mize the risk of endometrial hyper- perience a brief exacerbation asso- luteal production of estrogen and plasia.2,3 Sometimes the addition of ciated with ovulation.8,11 progesterone. a progestin will create symptoms at- Seventy percent to 90% of The lifespan of the corpus lu- tributable to the steroid itself, or may women with menstrual migraine ex- teum is fixed at approximately 12 exacerbate the preexisting medical perience improvement during preg- days. If fertilization of the ovum does condition. Since endometrial hyper- nancy, especially during the sec- not occur, the corpus luteum invo- plasia would be unlikely to develop ond and third trimesters.9,10,12,13 lutes, levels of estrogen and proges- with 6 months of unopposed use of These women may experience mi- terone fall dramatically, and men- estrogen, estrogen add-back may be graine attacks in the postpartum pe- struation occurs. Falling levels of used on its own during a brief (3-6 riod, associated with falling estro- ovarian hormones remove the nega- months) diagnostic trial. gen levels.14 Oral contraceptives have tive feedback from the pituitary gland In gynecology, gonadotropin- a variable effect on migraine, caus- and hypothalamus, and a new cycle releasing hormone agonists are used ing headaches to worsen, improve, of ovarian stimulation begins.1 to temporarily suppress ovarian ste- or show no change.15 Analogous to roid secretion to treat such condi- women with menstrual migraine, GONADOTROPIN-RELEASING tions as endometriosis, precocious some users of oral contraceptives HORMONE AGONISTS puberty, uterine leiomyomas, pre- experience headaches only during menstrual syndrome,4 and for pre- tablet-free or placebo days.16 Al- Gonadotropin-releasing hormone vention of menstruation in specific though the prevalence of migraine agonists are analogues of gonado- clinical situations (eg, thrombocyto- headaches decreases with advanc- tropin-releasing hormone, the hy- penia or leukemia).3 They can also be ing age, migraine can either regress pothalamic hormone that binds to used as diagnostic tools to confirm or worsen at menopause.17 specific receptors in the anterior pi- the relationship of the menstrual Migraines are vascular head- tuitary gland, stimulating the re- cycle to conditions such as premen- aches, associated with a vasocon- lease of gonadotropins. Gonadotro- strual syndrome and menstrual mi- strictive phase followed by vasodila- pin-releasing hormone agonists, by graine.3 If symptoms or cyclic exac- tation.18 Factors thought to trigger binding to gonadotropin-releasing erbations resolve with elimination of these vascular changes include ab- hormone receptors, cause an initial the ovarian cycle, a link to the men- normal platelet aggregation, altered increase in follicle-stimulating hor- strual cycle is confirmed. These pa- platelet content of serotonin, aber- mone and luteinizing hormone se- tients generally have excellent symp- rant neurotransmitter activity, and cretion, the so-called flare effect. Af- tomatic relief with continued use of central opioid disregulation.19-22 In ter about 1 week however, down- gonadotropin-releasing hormone menstrual migraine, estrogen with- regulation and desensitization of the agonists or after surgical oophorec- drawal is likely responsible for pituitary gland produces a hypogo- tomy. Gonadotropin-releasing hor- initiating some or all these vascular nadal state, sometimes likened to a mone agonists have also been used effects on intracranial vessels. Estro- “medical oophorectomy.”2 to treat a variety of medical condi- gen regulation of prostaglandin pro- Adverse effects of gonadotro- tions with severe, potentially life- duction may also be directly or indi- pin-releasing hormone agonist treat- threatening menstrual cycle– rectly involved with the pathogenesis ment are related to hypoestrogen- related exacerbations, examples of of menstrual migraine.11,23 ism, including hot flushes, headache, which are discussed in this review. Several investigators24-27 have vaginal dryness, and sleep distur- demonstrated an effect of estrogen bances. The adverse effect of great- MENSTRUAL MIGRAINE on the vasculature.It has been pro- est concern however, is accelerated posed that in women with men- bone loss, putting the patient at in- The evidence supporting a relation- strual migraine, estrogen may sen- creased risk for osteoporosis if con- ship between estrogen withdrawal sitize intracranial vessels, making tinued for prolonged periods (Ͼ6 and migraine headache is compel- these vessels more responsive to hor- months). This effect, and the hy- ling. Migraine headaches are 2 to 3 monal changes, leading to vasocon- poestrogenic symptoms, can be pre- times more common in women than striction associated with estrogen vented by the addition of estrogen men,5 a sex difference that does not withdrawal.28 Estrogen administra-

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Downloaded From: https://jamanetwork.com/ on 09/23/2021 tion to women with menstrual mi- recent report40 demonstrated dra- creased by estrogen, an effect pre- graine can preclude the expected mi- matic success in treating menstrual sumably caused by alterations in graine attack until the use of estrogen migraine with gonadotropin- brain excitability.46 A decrease in the is discontinued.28 The response to es- releasing hormone agonists, com- progesterone level, or in the proges- trogen withdrawal is triggered by the bined with continuous low-dose es- terone-estrogen ratio, correlates with abrupt decline in estrogen levels, trogen replacement therapy. Women increased seizure activity.47 Fre- rather than by any absolute level.28 who respond to this treatment typi- quency of seizure has been shown Progesterone administration, while cally can expect to experience long- to increase during 2 specific times delaying menstrual flow, does not term relief following surgical oopho- in the menstrual cycle. The first cor- prevent the occurrence of migraine rectomy with low-dose estrogen responds to the rapid decrease in at the expected time.28 replacement therapy. Concomitant progesterone just before menses, and Treatment of menstrual mi- hysterectomy, while unnecessary for the second to the elevation of estro- graine may be symptomatic or pro- migraine prevention, simplifies gen before ovulation.46,48 An in- phylactic. Ergotamine tartrate, an- subsequent hormone replacement crease in frequency of seizure has algesics, and antiemetics will provide therapy, allowing replacement with also been demonstrated during an- symptomatic relief in most women. estrogen alone and avoiding the need ovulatory cycles when progester- Nonsteroidal anti-inflammatory for progestin, which at times trig- one levels are relatively low.49 Fi- agents are occasionally effective in gers recrudescence of migraine. For nally, menopause or oophorectomy women with menstrual migraine.29 the few women who experience ex- may lead to significant improve- Prophylactic therapy is indi- acerbation of migraine headaches ment in epilepsy.50 cated for women with menstrual while receiving estrogen replace- Menstrual abnormalities and migraine who do not experience ad- ment therapy, several strategies have gynecologic syndromes such as poly- equate relief from symptomatic treat- been suggested including reduction cystic ovaries, hypogonadotropic ment. The occurrence of migraine of estrogen dose, continuous rather and hypergonadotropic hypogonad- headaches at predictable times each than cyclic estrogen administration, ism, oligomenorrhea, and amenor- month permits tailored use of pro- and changing the type or route of ad- rhea are more common in women phylactic medications such as er- ministration of estrogen.29 with epilepsy.51-55 This could result gotamine, ␤-blockers, calcium chan- directly from the effects of anti- nel blockers, and antidepressants.29 CATAMENIAL EPILEPSY convulsant medications on the hy- Because estrogen withdrawal is im- pothalamic-pituitary axis, or indi- plicated in the pathogenesis of Catamenial epilepsy is observed in rectly through alterations in the menstrual migraine, it may be more 10% to 70% of women with epi- metabolism of sex steroids. Women physiologic to treat these women pro- lepsy.41,42 The wide range in re- with temporal lobe epilepsy are par- phylactically with estrogen.15,30-34 Es- ported incidence is because of the ticularly prone to anovulation. Dys- trogen, which can be administered in lack of a generally accepted defini- function of the limbic cortex, which either oral or percutaneous form, is tion of catamenial epilepsy.42 Up to is extensively interconnected with started 48 hours before the antici- 70% of women with epilepsy claim the hypothalamus, appears to alter pated onset of headache at midcycle that most of their seizures are exac- the release of hypothalamic hor- or at menstruation, and is contin- erbated by menstruation.42 Strictly mones and pituitary gonadotro- ued for 3 and 6 days, respectively. Es- defined, however, catamenial epi- pins, resulting in anovulation.56 tradiol (1 mg) taken sublingually im- lepsy is epilepsy that occurs at or Altered metabolism of anticon- mediately at the onset of aura may worsens around menstruation, and vulsants at different times in the interrupt the usual progression to can be objectively demonstrated in cycle is well established. Decreased migraine headache.35 approximately 12% of women with serum levels of phenytoin demon- Tamoxifen citrate is reported to epilepsy.42 A strict definition is im- strated during menses in women relieve menstrual migraine.15,36 Re- portant as it has implications for with catamenial epilepsy correlate cent reports37 indicate that sumatrip- management of seizure. Menstrual with increased seizure activity.51-57 tan succinate, a 5-hydroxytrypta- exacerbations occur with all types of The decrease in estrogen and pro- 43 mine1 receptor agonist, is also seizures. Catamenial epilepsy is be- gesterone at menstruation is be- effective. There is no evidence to sup- lieved to result from cyclic alter- lieved to stimulate the release of port the use of progesterone in the ations in both ovarian hormone lev- hepatic monoxygenase enzymes, treatment of menstrual migraine. els and drug metabolism. which accelerates anticonvulsant Use of medications that suppress The evidence that ovarian ste- metabolism, and increases the risk the hypothalamic-pituitary-ovarian roid fluctuations are involved is com- for breakthrough seizures.58 Treat- axishavebeensuccessfulfortreatment pelling. In women who develop cata- ment of catamenial epilepsy re- of women whose menstrual migraines menial epilepsy, seizures frequently quires measurement of serum lev- are refractory to the usual therapies, start at or shortly after menarche.44 els of anticonvulsants during times or in whom migraines are problem- Patients with mixed seizure types of seizure exacerbation, with alter- atic at times other than at midcycle show increased electroencepha- ations in dosing as appropriate to im- or at menstruation (usually luteal). lographic activity during men- prove seizure control.47 Danazol, an androgen derivative, has struation.45 Seizure threshold is Many investigators47,48,59-62 have shown variable effectiveness.15,38,39 A increased by progesterone and de- shown progesterone therapy to be

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Downloaded From: https://jamanetwork.com/ on 09/23/2021 beneficial. Medroxyprogesterone ac- days before menstruation. Its relax- thritis by demonstrating a significant etate given orally (10-40 mg once ant effect on smooth muscle contrac- decline in mean grip strength at the daily) or intramuscularly (150 mg ev- tility may contribute to cyclic changes start of menstruation. Similarly, the ery 6-12 weeks) has been the most in airway responsiveness in women size of finger joints peaked within 6 widely tested.47,60 In addition to its with menstrual cycle-related exacer- days of the start of menstruation, antiepileptic properties, progester- bations of asthma.41 Progesterone- corresponding in many cases with one given in this fashion may also re- stimulated hyperventilation may fur- increased body weight.80 duce frequency of seizure by sup- ther influence asthma leading to The abrupt decline of ovarian pressing gonadotropin release which, symptomatic deterioration and dys- steroidogenesis resulting from invo- in turn, lowers estrogen levels.48,61 pnea.69,70 Although a luteal increase lution of the corpus luteum is thought The effects of combined oral con- in asthma symptoms and decrease in to be responsible for “menstrual ar- traceptives on frequency of seizure peak expiratory flow rates have been thritis,” a rare condition in which ar- have been inconsistent, with sei- demonstrated, an associated deterio- thritis occurs exclusively at the time zure exacerbation occurring on the ration in airway reactivity has not of menses.81 Cyclic alterations in pill-free days according to some re- been shown.71 There is also no rela- rheumatoid arthritis may be attrib- ports.47 Uninterrupted combined use tionship between airway function and utable to menstrual cyclicity in the of oral contraceptives or the proges- absolute levels of progesterone. Al- immune response. Cyclic changes in tin-only oral contraceptive may be though some prostaglandins have local antibody release82,83 and in white preferable in women with epilepsy as bronchoconstrictive effects, endog- blood cell subpopulations84 have been they result in continuous progestin enous prostaglandin synthesis has described. Both estrogen and proges- exposure.45 Since efficacy of oral con- shown no correlation with premen- terone have anti-inflammatory prop- traceptives may be decreased in pa- strual asthma.72 The lack of defini- erties that may ameliorate arthritic tients with epilepsy receiving anti- tive evidence for either progester- symptoms.85,86 Premenstrual exacer- convulsant therapy because of one or prostaglandin mediation has bation of symptoms has also been accelerated metabolism of the con- led to the theories that premen- attributed to altered pain percep- traceptive steroids, a higher dose (50 strual asthma may in part be due to tion associated with premenstrual µg) of oral contraceptive pills are rec- altered perception, or heightened alterations in mood.80 ommended. The use of ovarian sup- awareness of symptoms.66,73 Men- Estrogen, either alone87 or in the pressive agents such as danazol and strual cycle-related alterations in im- combination oral contraceptive pill,88 gonadotropin-releasing hormone mune mechanisms have also been has proved beneficial for some women agonists with steroid add-back for suggested.74 with rheumatoid arthritis. Oral con- control of seizure has not been de- Treatment for premenstrual traceptives may delay onset of dis- scribed in the literature. It may be asthma includes the usual medica- ease, but do not prevent its occur- worthwhile to consider these medi- tions for asthma: ␤-adrenergic ago- rence.89-91 Although not as thoroughly cations in patients refractory to the nists, anticholinergics, and cortico- studied, estrogen replacement therapy anticonvulsant and hormonal thera- steroids.41 Intramuscular progesterone in postmenopausal women appears pies previously discussed. was shown to be effective in 3 women not to protect against the occur- with severe, refractory premenstrual rence of rheumatoid arthritis.92,93 ASTHMA asthma, eliminating the decrease in peak flow rate, as well as reducing to- IRRITABLE BOWEL The observation that asthma is in- tal corticosteroid requirement.75 The SYNDROME fluenced by gonadal steroids is sup- use of danazol, intramuscular me- ported by the fact that asthma is droxyprogesterone acetate (Depo- Irritable bowel syndrome is a com- more common in females after pu- Provera), or gonadotropin-releasing mon gastrointestinal disorder, diag- berty.63,64 In many women there is hormone agonists to suppress men- nosed clinically by the triad of an increased frequency and sever- strual cyclicity remains a promising chronic or recurrent abdominal pain, ity of attacks premenstrually or at area for investigation. altered bowel habits, and the ab- menstruation.65 Gibbs et al66 objec- sence of a structural or biochemi- tively confirmed the worsening of RHEUMATOID ARTHRITIS cal abnormality.94,95 Symptoms of asthmatic symptoms premenstru- irritable bowel syndrome appear in ally by documenting significant de- Symptoms of rheumatoid arthritis late adolescence and affect women creases in peak expiratory flow rates. often improve in the luteal phase 3 to 20 times more frequently than Women are also more likely to be when gonadal steroid production is men.94,96 In women, symptoms tend hospitalized premenstrually for maximal. Similarly, improvement is to recur and become cyclic, with ex- asthma complications, including res- seen during pregnancy, with exac- acerbation during the postovula- piratory failure.67,68 erbation postpartum.76-78 A subjec- tory and premenstrual phases of The precise cause of premen- tive increase in morning stiffness and the menstrual cycle, suggesting a strual asthma remains elusive, but arthritic pain during menstruation hormonal influence.97,98 Women may be related to changing levels of and the early follicular phase has in the ovulatory phase frequently progesterone or prostaglandins. Pro- been shown.79 Rudge et al80 objec- report constipation in the progesterone, increases steadily after tively documented menstrual cycle– gesterone-dominant luteal phase, ovulation, and falls abruptly in the related variations in rheumatoid ar- with loose stool or diarrhea at, or

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Downloaded From: https://jamanetwork.com/ on 09/23/2021 immediately preceding, the onset the gut, mediated through ovarian teal phase and premenstrually,129-132 of menstruation. hormone suppression.110 This possi- and is another possible cause for loss Progesterone has well-docu- bility is supported by limited evi- of glycemic control in women with mented effects on the gastrointesti- dence that gonadotropin-releasing diabetes during this time. nal system, including a reduction in hormone agonists provide relief from The exact mechanism of men- lower esophageal sphincter tone and irritable bowel syndrome in men and strual cycle–related effects on glu- delayed gastric emptying.99,100 De- in menopausal women.111 The ex- cose homeostasis in women with layed gastrointestinal transit time in pense and potential adverse effects of diabetes is enigmatic. In practical women, particularly during the lu- these medications will preclude pro- terms however, women with diabe- teal phase, has also been demon- longed use in most circumstances. tes should be counseled regarding strated.101-103 Progesterone may act Rarely, if dramatic relief results from the possibility of altered control. as an endogenous antagonist of en- a trial of ovarian suppression, ovari- They need to recognize changes in teric nerve function.98 Abrupt pro- ectomy and low-dose estrogen re- their eating patterns and adjust in- gesterone withdrawal may trigger an placement may have a therapeutic sulin dosages accordingly. Ovarian increase in bowel activity. role. suppression with gonadotropin- Gastrointestinal symptoms such releasing hormone agonists has been as abdominal pain, diarrhea, and con- DIABETES used in women with recurrent life- stipation are consistently reported by threatening complications, such as women with irritable bowel syn- Menstrual cycle–related alterations in recurrent severe insulin reactions or drome, in association with the men- glycemic control during the luteal ketoacidosis associated with spe- strual cycle.104-108 The most dramatic and premenstrual phases in some in- cific phases of the menstrual cycle, changes in bowel symptoms occur at sulin-dependent individuals with dia- with good effect.113 the start of menstrual flow, a time betes have been reported.50,112-115 Most when the levels of progesterone fall, women describe a deterioration in MISCELLANEOUS DISORDERS and prostaglandin E2 and F2 alpha, glycemic control, although improve- powerful stimulants of colonic con- ments have also been noted.113,114 Dia- The previous discussion describes the tractility, rise.104,105,109 Patients with ir- betic ketoacidosis, severe insulin re- effects of the menstrual cycle on sev- ritable bowel syndrome, in whom the actions, and hypoglycemic episodes eral relatively common disorders. colon is hyperresponsive to a variety also occur more frequently around Several rare conditions show men- of stimuli, may have an exaggerated menstruation.113,114 In one excep- strual variation in severity. There are colonic response to prostaglandins re- tional case, insulin resistance and ke- numerous case reports of catame- leased during menstruation.97 toacidosis recurred exclusively dur- nial pneumothorax, the occurrence Treatment of irritable bowel ing menstruation.116 of recurrent spontaneous pneumo- syndrome is generally symptomatic, Altered insulin receptor bind- thorax exclusively associated with including antispasmodic and promo- ing and affinity at different times dur- menses, possibly the result of pleu- tility agents, and bulk-forming laxa- ing the menstrual cycle have been re- ral or diaphragmatic endometrio- tives. The theory of prostaglandin in- ported in some,117-119 but not all120 sis.133-139 This has been successfully volvement in menstrual-related studies. Attempts to identify the hor- treated with gonadotropin-releas- exacerbations of irritable bowel syn- mones responsible for menstrual cy- ing hormone agonists.140 drome raises the possibility of treat- cle–related changes in carbohydrate There is some evidence that ment with prostaglandin synthesis metabolism have produced conflict- acute appendicitis presents more fre- inhibitors. ing results. Impaired glucose toler- quently in the luteal phase,50,141-143 There have been several re- ance during the luteal phase is re- although this could be because of ports98 of successful treatment of ir- ported in healthy women without the misdiagnosis of pain in the ritable bowel syndrome with go- diabetes.121,122 In studies123-125 on the rght lower quadrant resulting from nadotropin-releasing hormone effects of oral contraceptive, physi- corpus luteal cysts, leading to un- agonists. With the menstrual cycle ologic levels of estrogen were found necessary appendectomy. Other dis- completely eliminated, these women to have minimal effects on carbo- orders exacerbated by the postovu- experience significant and progres- hydrate metabolism in women latory and premenstrual phases of sive improvement in bowel symp- without diabetes. Studies126-128 of the menstrual cycle include acne, en- toms. Interestingly, many of these progestational agents have also dem- docrine allergy and anaphylaxis, he- women experienced transient recur- onstrated variable effects. It is pos- reditary angioedema, erythema mul- rence of their symptoms during the sible that even small effects of estro- tiforme, urticaria, aphthous ulcers, progestin phase of the estrogen and gen and progesterone on glucose Behc¸et syndrome, acute intermit- progestin add-back therapy, given to homeostasis are exaggerated in tent porphyria, paroxysmal supra- minimize the long-term adverse ef- women with diabetes, in whom the ventricular tachycardia, glaucoma, fects associated with gonadotropin- normal feedback regulation be- and multiple sclerosis.41,144-149 Go- releasing hormone agonists.98 It is tween plasma glucose levels and in- nadotropin-releasing hormone ago- likely that gonadotropin-releasing sulin secretion is lost.112 Loss of eat- nists have been used for some of hormone agonists have direct ef- ing control, such as bingeing or these conditions, in particular for re- fects on the enteric nervous system, increased intake of sweets, is de- current anaphylaxis and acute in- in addition to their indirect effects on scribed by many women in the lu- termittent porphyria, when symp-

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