Hormone Replacement Therapy

HRT involves administration of estrogen and progesterone hormones to counteract their dipping levels during menopause. Earlier ERT (Estrogen Replacement Therapy) was followed but this is now replaced by combined hormone therapy. HRT provides relief from symptoms such as increased fatigue and irritability and depression. Hormone Replacement Therapy is usually followed for a few months or a couple of years.

HRT is known to prevent or alleviate any bone loss that leads to osteoporosis. Women who have been on HRT experience enhanced sexuality and improved pelvic floor muscles. It may prove beneficial in preventing Alzheimer's disease and macular degeneration. Cyclic hormone therapy involves taking estrogen pills for 25 days, switching to progestin in between 10 - 14 days and then taking a combined pill for the next 25 days. Stopping the HRT for about 4 days brings on the menstrual bleeding.

The other form of administering HRT is continuos or combined therapy - whereby estrogen and progestin are taken everyday in combined form. Women on HRT complain of a bloated feeling as well as terrible headaches and fluid retention.

HRT Side Effects Some women experience post-menopausal bleeding when on HRT. Tender and swollen breast are yet another side effect of HRT. Swelling of the legs and increased weight are also noticed by women on HRT. Other associated risks of HRT are increased incidence of venous thrombosis or worsening of any existing liver condition. Long-term use of HRT is associated with breast cancer.

HRT patch

An HRT patch is an alternative to hormone tablets and vaginal creams. When ingested in tablet form, the hormone moves from the stomach and intestines to your liver. This necessitates higher dose of estrogen to be administered. HRT patches allow the skin to absorb estrogen through the bloodstream. HRT patches are worn on any location below your waist.

But it must never be applied on or near the breasts. Women suffering from sore or irritated skin must not use HRT patches. Vaginal creams containing estrogen are yet another method of administering HRT. This reduces the feeling of dryness experienced by most peri-menopausal women.

Kallmann Syndrome

A rare hormonal condition characterized by delayed or absence of puberty and an impaired sense of smell is Kallmann syndrome. This belongs to a larger group of conditions known as hypogonadotrophic hypogonadism. This condition is usually characterized by a failure to start or fully complete puberty. However hypogonadotrophic hypogonadism can be treated successfully by means of specialized hormone replacement therapy.

It is estimated that this syndrome affects 1 in 10,000 to 86,000 people and occurs more often in males rather than in females. Kallmann Syndrome 1 is the most common form of this condition. It was Franz Kallmann, an American scientist who first published a paper in 1914 about this syndrome. Therefore this genetic condition is named after him.

Characteristics of Kallmann Syndrome

Males with hypogonadotrophic hypogonadism are born with unusually small penis and undescended testes. Whereas, females affected, usually do not begin menstruating at puberty and have little or no breast development at all. In some women, puberty is either incomplete or delayed. In short, at puberty those affected do not develop secondary sexual characteristics.

In Kallmann syndrome, the sense of smell is particularly diminished or completely absent. This feature indeed distinguishes this syndrome from most other forms of hypogonadotrophic hypogonadism.

The significant aspect here is that most patients are not aware of this inability to detect odors until they are diagnosed. Some points to remember:

Inability to smell strong warning smells such as smoke or gas.

Inability to smell caustic products such as bleach.

Inability to smell rotten/spoilt food.

Personal hygiene, body odor and clothes.

Since the sense of smell is also linked to the sense of taste, some foods will not taste the same as with other people.

Signs and Symptoms

Kallmann Syndrome, even within the same family may vary in its features. Some additional symptoms and signs may include failure of one kidney to develop, a cleft lip with or without an opening in the roof of the mouth or a cleft palate, abnormal eye movements, hearing loss and abnormalities in tooth development.

In some affected persons, the movements of one hand are mirrored by the other hand - Bimanual Synkinesis. This can make it difficult to undertake tasks that require the hands to move separately such as playing a musical instrument. Kallmann syndrome has types designated from 1 through 4 distinguished by their genetic cause. The four types are identified as four forms of Kallmann syndrome, each characterized by an impaired sense of smell. Additional features of cleft palate occur only in types 1 and 2.

Causes

Kallmann syndrome and other related conditions are congenital in nature and are present from birth. Their genetic basis may not be fully understood and this syndrome can be inherited through the generations although it is difficult for the doctor to predict if this will occur.

The genetic factor: Certain mutations in the KAL1, FGFR1, PROKR2, and PROK2 genes cause Kallmann syndrome. Mutations in FGFR1 gene causes syndrome type 2 and mutations in PROKR2 and PROK2 cause Kallmann syndromes types 3 and 4 respectively.

These genes seem to play a role in the development of the brain much before birth. They are involved in the formation and movement of a group of nerve cells that are specialized in olfactory or smell process. The mutations KAL1, FGFR1, PROKR2, and PROK2 genes which play a role in the migration of neurons that produce a hormone called GnRH – Gonodotropin releasing hormone that controls several other hormones that direct sexual development before birth and during puberty. These hormones are necessary for the normal functioning of the ovaries in women and testes in men. These mutations disrupt the olfactory nerve cells and GnRH producing nerve cells in the brain. However these conditions and features vary among individuals and thus additional genetic and environmental factors may be involved.

Treatment

Without proper treatment, the affected female is likely to face infertility and have an increased risk of developing osteoporosis or brittle bones. However, with correct diagnosis and treatment, fertility can be achieved in many cases and risk of osteoporosis decreased.

Following clinical examination, certain biochemical parameters and various imaging tests are done to confirm the diagnosis. As this is a genetic condition, testing for various genetic forms of this disease may also assist in making the diagnosis.

Initially hormone replacement therapy - testosterone in males and estrogen and progesterone in females is used to help induce secondary sexual characteristics.

Once pubertal maturation happens, for fertility either injection of pituitary hormones – gonadotropins, LH and FSH and in some instances therapy with synthetic peptide, GnRH is given. Deficiency of these hormones causes syndromes, and these are required to induce the sex organs to make sperm in males and eggs in females.

In females, the steps taken may vary depending upon individuals and the desired outcome. In premenopausal women, a step-by-step increase in estrogen dosage is given. A bone scan is done to assess the bone age. Without the presence of estrogen, the bone age will be behind that normally seen at that chronological age. The aim is to match the estrogen dosage to the bone age such that the development of bone can be enhanced. The doctor usually monitors the stage of treatment very closely.

Specialist fertility treatments are available and these can induce a certain level of fertility. The aim is to produce hormones by the pituitary and hypothalamus glands and induce natural production of sex hormones. Results can take 6 to 18 months but it is possible to induce fertility in some cases.

There are various drugs available which are usually self-injected twice or thrice a week over a period of at least six weeks. To combat the risk of osteoporosis, it becomes necessary to take tablets that reduce the risk. These tablets help increase the calcium uptake by the bones to strengthen them. However, medication will not eliminate the risk of osteoporosis.

Early diagnosis, education, personal outlook and support from family and friends can help reduce the problems surrounding this syndrome. Kallmann syndrome is usually lifelong in nature and about 10-15% of patients may experience recovery of hormonal system.

Gingivitis

Gingivitis involves inflammation of the gums surrounding the teeth. Due to this, the gums become soft and swollen and usually red instead of a healthy pink. The inflammation of the gums is a defense mechanism put up by the body's immune system to prevent the growth of bacteria which along with the remnant food particles and plaque form tartar. This cannot be removed by simple brushing or flossing.

What Causes Gingivitis Disease?

The primary cause of gum disease is plaque. However, there are various other reasons why gingivitis disease develops.

• Gums become sensitive when there are hormonal changes in the body, such as during puberty, pregnancy, menopause and menstruation. During pregnancy, hormonal changes and tartar induce excessive growth of gum tissues resulting in the formation of lumps commonly referred to as pregnancy tumors. These tumors prevent bacteria from being removed effectively during brushing, thus resulting in gingivitis disease.
  
  
• In post-menopausal women, a painful condition called desquamative gingivitis may develop, for reasons yet unknown. In this condition, the outer layers of the gums come away from the teeth and lose their solidity, resulting in the exposure of nerve-endings which causes acute pain.
  
  
• Long-term use of contraceptive pills can also result in gingivitis.
  
  
• Diseases that affect the immune system such as HIV or cancer may also affect the gums. Diabetes when uncontrolled, can affect the gums. On the other hand, gingivitis disease may also be a pointer to systemic disorders.
  
  
• Some medications can also cause gum disease as they restrict production of saliva which prevent the formation of tartar. Some medications used in the treatment of angina and seizures can cause abnormal growth of the tissues in the gums.
  
  
• Habits, such as smoking, do not facilitate the easy self-repair of the gums. A severe form of gingivitis, known as Trench mouth or ANUG (Acute necrotizing ulcerative gingivitis) is mostly found in the case of smokers. ANUG is also reported in the case of incapacitated persons under severe stress. Acute pain, swelling, bleeding and bad breath develop very quickly in this condition and also the gums turn grey.
  
  
• If gingivitis runs in the family, then there is a greater chance of a person getting it. Poor oral hygiene is a major contributor to gingivitis.
  
  
• Dental appliances not properly fitted or improper alignment of teeth may also cause gingivitis.
  
  
• Dietary imbalances, vitamin deficiencies, and drug reactions can also result in gingivitis.
  
  
• Gingivitis disease is also often caused by fungal and viral infections.
  
  

Symptoms of gingivitis

There is usually no pain associated with mild form of gingivitis. Hence it may go unnoticed. However, there are certain symptoms that warn that treatment for gingivitis is needed:

• When the gums are swollen, soft, or red.
  
  
• When gums bleed during, or after brushing.
  
  
• When bad breath or bad taste in the mouth persists even after brushing and flossing.
  
  
• When the gums recede.
  
  
• Deep pockets are formed between teeth and gums.
  
  
• Visible deposits of tartar.
  
  

If the dentist finds that someone is particularly prone to formation of plaque, he may recommend use of special implements to remove plaque, such as toothpicks, electric toothbrushes etc. This treatment for gingivitis would suffice when the gingivitis disease is in the early stages.

For reducing the pocket depth between teeth and gums, which can also cause gingivitis, dentists undertake root-planing and scaling. In addition dentists may also administer minocycline microspheres. For women who have desquamatic gingivitis, hormone replacement therapy could be beneficial. However, adverse effects of the therapy could prevent their recommendation. Instead, corticosteroid rinses and pastes which can be directly applied on gums may be more commonly recommended.

Pericoronitis is acute, painful inflammation of the gingival tissue over a partly erupted tooth (as in the case of a wisdom tooth). The treatment for this would include removal of the debris beneath the gingival flap and irrigation with saline. This may be followed up with extraction, particularly when there is recurrence of the episode.