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CONTRACEPTION IN WOMEN WITH THYROID PATHOLOGY

The thyroid gland is located in the front of the neck, anterior to the trachea and esophagus. Along with the nervous and immune systems, it coordinates and regulates the activity of other body systems, allowing you to adequately respond to constantly changing conditions of the internal and environmental.

The main thyroid hormones are thyroxine and tri-iodothyronine, usually referred to as T4 and TK (the number indicates the number of iodine atoms in the molecule of this substance). For the synthesis of these hormones, iodine is needed that enters the body from the external environment (with food and water, and, if necessary, in the form of special preparations). The synthesis activity of these hormones is regulated by the pituitary gland, which secretes a thyrotropic hormone that stimulates the gland. This hormone is of great practical importance. In particular, with a decrease in the synthesis of hormones by the thyroid gland (for example, with partial destruction of its tissue), the pituitary gland enhances its stimulation, increasing the production of thyroid stimulating hormone, temporarily returning the levels of TK and T4 to normal. Therefore, an increase in the level of thyroid-stimulating hormone is an earlier sign of destruction of the tissue of the thyroid gland than a decrease in the level of hormones of the thyroid gland itself. The opposite picture is observed with excessive synthesis of hormones by the thyroid gland.

In recent decades, thyroid diseases have been steadily progressing in the structure of endocrine pathology, and in the coming years a further increase in the number of such patients should be expected due to the deteriorating environmental situation (Dedov I.I. et al., 2003).

Thyroid diseases can occur in two main forms. The first form is characterized by a violation of the synthesis of its hormones: hypothyroidism (deficiency) and hyperthyroidism (excess, or thyrotoxicosis). The second form of disorders is reduced to a change in the structure of the organ: a diffuse increase in size and the formation of seals in the gland limited by the capsule (nodes).

An enlarged thyroid gland is called goiter. However, according to current recommendations, such a diagnosis can be made only with a true enlargement of the gland, when



Fig. 4.1. The chemical structure of chlormadinone acetate.

A well-made ultrasound examination allows calculating its volume. The normal thyroid volume is 18 cm3 for women and 25 cm3 for men. Anomalies in the structure of the gland and a change in function often do not match. Therefore, the diagnosis usually indicates both changes in the structure (size) of the gland, and the state of its function.

The most common thyroid diseases in Russia are nodular formations against the background of normal levels of hormones. One of the common causes of thyroid damage is iodine deficiency, which causes iodine deficiency diseases.

Problems associated with the pathology of the thyroid gland and the state of the reproductive system of women are of great theoretical and practical interest for gynecological endocrinology. Thyroid function is closely associated with the hypothalamus – pituitary – ovary system, primarily due to the presence of common central regulatory mechanisms. In turn, the state of the reproductive system has a pronounced effect on the function of the thyroid gland. Confirmation of these relationships is a change in thyroid function during pregnancy and lactation, in patients with dysfunctional uterine bleeding, as well as in girls during puberty and in women during the menstrual cycle. The close relationship of the thyroid gland and the reproductive system is also indicated by the occurrence of thyroid pathology after childbirth.

Despite the controversial nature of information about the effect of sex hormones on thyroid function, most



Most researchers believe that estrogens have a stimulating effect on the thyroid gland. Thus, castration leads to a significant decrease in the secretion of thyroxine, and replacement therapy with estrogens contributes to its normalization. As for the effect on the function of the thyroid gland of progesterone, the researchers recognized its inhibitory effect.

Currently, a close relationship has been established between thyroid gland pathology and impaired generative function of women. There is an opinion that primary hypothyroidism is accompanied by menstrual irregularities of the type of hypomenstrual syndrome amid a decrease in the production of both estrogen and progesterone. A rare form of menstrual irregularities in hypothyroidism is amenorrhea, the frequency of which with this type of thyroid pathology varies from 1.5 to 6% (Sosnova E.A., 1989; Prilepskaya V.N. et al., 1990; Varlamova T.M. ., 2005). It should be noted that in patients with hypothyroidism, reproductive dysfunctions are also detected with a regular menstrual cycle. Moreover, insufficiency of the luteal phase of the cycle and anovulatory menstrual cycles occur in patients with hypothyroidism with approximately the same frequency (Doufas A. et al., 2000).

An important symptom observed with impaired thyroid function is galactorrhea, the frequency of which varies. It is believed that the anterior pituitary gland is the main link through which the interaction between the ovaries and the thyroid gland occurs. It has been shown that both estrogens and thyroid hormones can alter the secretion of thyroid-stimulating hormone and prolactin (PRL) by influencing the different levels of regulation of the synthesis and secretion of thyroid-stimulating releasing hormone (TRH) and specific hormonal reactions of the anterior pituitary gland. Levels of TRH and PRL also change as a result of the stimulating effect of estrogen and the inhibitory effect of thyroid hormones. In addition, it was found that an imbalance of thyroid hormones can change the concentration of active steroids inside the target cells of the hypothalamus and pituitary gland, thereby violating the mechanism of positive and negative feedbacks.

The relationship of the thyroid and reproductive systems is carried out not only through the hypothalamic-pituitary mechanisms, but also at the level of peripheral hormones. Considering the mechanisms of the influence of hypothyroidism on the reproductive system, the functional state of the gonads can be explained by a decrease in metabolic processes in the body with this pathology. A decrease in ovarian sensitivity to gonadotropins



in conditions of reduced metabolism; it is also possible that a deficiency of thyroid hormones can directly affect estrogen metabolism, disrupting the transition of estradiol to estrone (Bongers-Schokking J. et al., 2000).

With diffuse toxic goiter, a change in the secretion of sex hormones was observed, in particular, an increase in the concentration of estradiol is observed. Although the level of binding of sex hormones to blood transport proteins also increases, the level of free estradiol remains high against the background of decreased progesterone production. With thyrotoxicosis, the testosterone content increases, but the level of free testosterone decreases, as this increases the level of sex hormone-binding globulin, which binds more to testosterone than to estradiol. An increase in the metabolism of androgens to estrogens was noted. Perhaps this explains the presence of soft velvety skin with hyperthyroidism, as well as the possibility of treating hirsutism with thyroid preparations. Some authors believe that patients with diffuse toxic goiter are characterized by a change in the level of estradiol, progesterone and, to a lesser extent, the level of gonadotropins.

Thyroid diseases are among the most common diseases of the endocrine system in women older than 45 years. However, often their manifestation falls on the perimenopausal period.
When prescribing HRT to patients with hypothyroidism, it should be borne in mind that estrogen therapy increases the content of thyro-syncing globulin and reduces the content of free fractions of thyroid hormones, which can lead to decompensation of hypothyroidism and require dose adjustment of L-thyroxine (Kakhturia Yu.B. et al., 2004).

The veiled symptoms of thyroid insufficiency are often not recognized by doctors on time, and complaints about the cessation of menstruation, menstrual irregularities and infertility make these women patients of gynecologists. At the same time, arising abnormalities in the reproductive system are functional in nature and are caused precisely by the insufficiency of thyroid hormones in the body (T. Lobova, 1990).

If thyroid function deficiency is detected, pathogenetic treatment (correction of thyroid status) with thyroid hormones (L-thyroxine) and iodine preparations (potassium iodide) is necessary. Early diagnosis and adequate treatment of hypothyroidism leads to an improvement in the general condition, the disappearance of complaints and clinical manifestations of thyroid failure, as well as disorders of



Productive system. At the same time, a number of authors indicate that treatment of thyroid problems leads to normalization of the reproductive system function without additional correction by sex hormones.

It should be emphasized that most women with thyroid pathology amid the correction of thyroid status are fertile, they have an ovulatory cycle and, therefore, they need contraception just like other women.

Hormonal contraception and its effect on thyroid function

The possibilities of contraception in women with thyroid pathology are quite wide, but often the doctor is in difficulty and does not imagine which hormonal contraceptive should be preferred and what contraindications should be taken into account.

It is known that in women taking combined oral contraceptives, the endogenous activity of the ovaries is suppressed, since synthetic hormones form a new hormonal environment. There are indications in the literature that estrogens, which are part of hormonal contraceptives, increase the secretion of various proteins in the liver, such as cortisol-binding globulin, testosterone-binding globulin and thyroxin-binding globulin, however, biologically active free fractions of hormones remain unchanged, while the level of insulin growth hormones, adrenal steroids, thyroid hormones and prolactin in some cases can increase (Olsson S. et al., 1986).

It is noted that against the background of hormonal contraception, changes in thyroid function resemble the situation during pregnancy with an increase in thyroxin-binding globulin and iodine bound to proteins. Prior to the introduction of new methods for measuring the level of free thyroxin, the evaluation of thyroid function was difficult. Currently, measuring the level of thyroid stimulating hormone and free T4 in women using oral contraception allows an accurate assessment of their thyroid status. (Goldzieher J., 2000).

The effect of various endogenous and exogenous hormones on thyroid function has been studied by many researchers. The available data are contradictory and, of course, require further detailed research in this direction.

In a number of studies, a slight effect or its absence on the level of thyroid stimulating hormone was noted when using low-dose combined oral con



traction, while the use of highly dosed oral contraceptives showed a significant suppression of thyroid function. Moreover, the restoration of thyroid-stimulating hormone levels to standard values ​​was observed 2-3 days after the cancellation of high-dose OK (Barsivala V. et al., 1974; Penttilla I. et al., 1983).

R. Knopp et al. (1985) noted a 30% increase in T4 levels when taking high-dose oral contraceptives containing 50 μg of ethinyl estradiol. At the same time, the change in thyroid function during pregnancy is more significant: the T4 level rises by more than 100% and returns to baseline after delivery.

The role of hormonal contraception in the pregravial preparation program for women with impaired reproductive function due to thyroid diseases was studied by Uzbek scientists D.A. Aliyev and M.Sh. Sadykova (2002). The territorial characteristics of the population of Uzbekistan are known to be characterized by a lack of iodine intake and a high frequency of thyroid dysfunction. The authors noted the positive effect of hormonal contraception when prescribing COCs of the type Tri-regol and Regulon on the state of the thyroid gland. They and other authors found a decrease in the volume of the gland and a softening of its consistency with goiter in connection with the blockade of the hypothalamic-hypophysical system (Zigismund V.A. et al., 2001). Moreover, changes in hemostasis were similar to those in healthy women (Fayzieva F.T. et al., 1988).

When taking three-phase COCs containing 30 μg of ethinyl estradiol, an increase in the level of thyroid-stimulating hormone by 20% was observed, followed by an increase in T4 by 40%, while the level of TK remained within the standard values ​​(Kuhl H. et al., 1985).

S. Olsson et al. (1986) studied the effect of pure progestin-based oral contraceptives and implants on thyroid function. The authors have proved that in most cases, purely progestin oral contraceptives do not affect the production of thyroid hormones or slightly increase their level, which is considered clinically insignificant.

Mirena LNG-IUD, which releases 20 μg of left-norgestrel into the uterine cavity daily, is an acceptable method of contraception in women with thyroid pathology, which is associated with the absence of a clinically significant effect of levonorgestrel on thyroid function (WHO, 2004).



A very interesting study was conducted by M.Vessey et al. (1987). The authors carried out a thorough analysis of the number of hospitalizations for thyroid disease and did not find a statistically significant difference in women using hormonal contraception and not using it.

The leading specialist in contraception, J. Guilleband, in his last guide (2005) notes that hormonal contraceptives can have a therapeutic effect on thyroid pathology.

Thus, based on the available data, it can be concluded that there is no negative effect of hormonal contraception on the state of the thyroid gland. The insignificant effect that is noted in some studies is considered clinically insignificant today.

According to the recommendations of WHO (2004), a group of women with thyroid pathology such as simple goiter, hypothyroidism and hyperthyroidism should be classified as category 1. This means that contraceptives such as COCs (low-dose drugs), pure progestin tablets, plantates, intravaginal rings, patches, copper-containing and hormone-containing intrauterine devices are recognized as safe today and can be assigned to this group of women without restrictions as well as healthy women. Nevertheless, monitoring the state of the thyroid gland in women using hormonal contraception should be carried out with the help of an endocrinologist, since in rare situations, dose adjustment of drugs prescribed by this specialist may be required. Acceptable methods are intrauterine contraception, the use of barrier methods and other non-hormonal methods.
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CONTRACEPTION IN WOMEN WITH THYROID PATHOLOGY

  1. Thyroid pathology
    Evaluation of thyroid function {foto256} Differential diagnosis of thyroid dysfunction {foto257} Signs of hyperthyroidism {foto258} Therapy of hyperthyroidism • ???? Antithyroid drugs: - profitiouracil; - methymeson; - b-blockers (propranolol). • ???? Subtotal thyroidectomy: - in preparation for surgery, the use of b-antagonists; - during operative
  2. PREGNANCY IN THYROID PATHOLOGY
    Complications of pregnancy associated with thyroid disease: 1) early abortion 2) severe forms of early gestosis 3) high incidence of fetal malformations - since thyroid hormones are necessary for normal differentiation of all body tissues. 4) accession of infection, fetal death from sepsis 5) rapid discharge of amniotic fluid
  3. Diseases of the thyroid gland and pathology of the reproductive system
    In the system of peripheral endocrine organs, the thyroid gland, along with the ovaries and adrenal glands, plays an important role in the functioning of the reproductive system of women. Various forms of thyroid pathology (thyroid gland) can cause puberty disorders, primary and secondary amenorrhea, anovulatory cycles, miscarriage and infertility. The influence of the thyroid gland on the reproductive system
  4. Diseases of the endocrine glands. Diseases of the endocrine pancreas. Diabetes. Thyroid disease. Thyroid tumors
    1. Etiological factors of diabetes 1. intoxication 2. tobacco smoking 3. helminth infections 4. viral infections 5. genetic predisposition 2. Pathogenetic mechanisms of the development of acute pancreatitis 1. duct dyskinesia 4. mushroom poisoning 2. biliary reflux 5. alcohol poisoning 3. gastroduodenal reflux 6. overeating 3. Match functional
  5. Thyroid disease
    Diseases of the thyroid gland in children are quite common and therefore have been studied quite fully. Среди заболеваний щитовидной железы у детей встречаются заболевания, сопровождающиеся повышением активности или ослаблением функции железы, воспалительные процессы, открытые и закрытые повреждения, а также злокачественные и доброкачественные опухоли. Патология щитовидной железы характеризуется не
  6. ЩИТОВИДНАЯ И ПАРАЩИТОВИДНАЯ ЖЕЛЕЗЫ. ВИЛОЧКОВАЯ ЖЕЛЕЗА
    ЩИТОВИДНАЯ И ПАРАЩИТОВИДНАЯ ЖЕЛЕЗЫ. ВИЛОЧКОВАЯ
  7. Заболевание щитовидной железы
    Наиболее частое заболевание щитовидной железы, выявляемое в отделении интенсивной терапии (ОИТ), — эутиреоидный синдром, который не является собственно заболеванием щитовидной железы, а скорее нарушением периферических связей и метаболизма гормона щитовидной железы под влиянием критического заболевания. Хотя значительный гипертиреоз или гипотиреоз встречается не так часто, глубокий избыток или
  8. ЩИТОВИДНАЯ ЖЕЛЕЗА
    Щитовидная железа — glandula thyreoidea (рис. 302) — развивается из энтодермального эпителия вентральной стенки кишки между первой и второй парами жаберных карманов. Сначала из эпителия образуется непарный вырост; последний разрастается в каудо-вентральном направлении, достигает области щитовидного хряща. Здесь клеточный тяж разделяется на две лопасти, которые, развиваясь, превращаются в правую и
  9. Рак щитовидной железы
    Рак щитовидной железы — это злокачественное моноклональное новообразование, которое характеризуется инвазивным автономным ростом и метастазированием и берет начало либо из фолликулярного эпителия, либо из парафолликулярных С-клеток. Первое упоминание о злокачественном новообразовании щитовидной железы у ребенка относится к 1880 г. Т. Winship и WW Chase (1955) нашли в мировой литературе к 1951
  10. Thyroid
    Щитовидная железа (ЩЖ) массой 15—20 г состоит из двух долей, связанных перешейком, лежащим на передней поверхности трахеи под криковидным хрящом. Состоит железа преимущественно из сферических тиреоидных фолликулов, между которыми располагаются кровеносные капилляры и нервные окончания. В щитовидной железе взрослого человека содержатся парафолликулярные клетки (К-клетки) в соединительной ткани
  11. Щитовидная железа.
    Щитовидная железа синтезирует два основных гормона: трийодтиронин(ТЗ) и тироксин(Т4). Эти гормоны являются одними из главных регуляторов основного обмена, следовательно, определяют рост ребенка, а также оказывают влияние на возбудимость нервной системы. Функция щитовидной железы тесно связана с функцией гипофиза, который регулирует ее активность по типу обратной связи с помощью тиреотропного
  12. Thyroid
    Physiology Iodine, which enters the human body with food, is absorbed into the digestive tract, where it transforms into iodides. Iodides with blood flow reach the thyroid gland, where they enter the thyrocytes by active transport. In the thyroid gland, iodide is oxidized to iodine, which combines with the amino acid tyrosine. As a result of this chemical process, two hormones are formed -
  13. Исследование щитовидной железы.
    Щитовидная же-леза у животных состоит из двух плоских долей, связанных между собой мостиком, и расположена по бокам первых трех колец трахеи. Исследу-ют ее при помощи осмотра и пальпации. Железу пальпируют одновре-менно двумя руками скользящими движениями, при этом определяют ее величину, консистенцию, подвижность и чувствительность. У лошадей доли щитовидной железы: небольшого размера и
  14. Болезни щитовидной железы
    Болезни щитовидной железы имеют особое значение, так как они очень широко распространены. Щитовидная железа контролирует множество метаболических процессов за счет гормонов тироксина (Т4) и трийодтиронина (Т3). Количество тиреоидных гормонов является важным показателем уровня метаболизма организма, включая окислительные реакции. В крови Т3 и Т4 находятся в связанном с белком состоянии. Control
  15. Болезни щитовидной железы.
    Щитовидная железа состоит из фолликулов, интерфолликулярных островков и парафолликулярных клеток. Фолликулы построены в основном из А-клеток, иногда содержат В-клетки (эозинофильные тиреоциты, онкоциты, клетки Ашкенази—Гюртле). А-клетки участвуют в образовании тиреоглобулина (коллоид), синтезе и секреции тиреоидных гормонов — йодтиронинов (прежде всего трийодтиронина и тироксина). В-клетки в
  16. Hyperthyroidism (hyperthyroidism)
    The reason is due to hyperfunction of the thyroid gland, an increased content of thyroid hormones in the blood plasma. Symptoms Symptoms associated with a change in the function of the pituitary gland: enlargement of the thyroid gland, ophthalmopathy (eyebrows), skin changes, including pretibial myxedema (thickening of the skin on the lower leg and foot, often with itching and burning), muscle weakness. Symptoms associated with
  17. Thyroid disease
    Большинство заболеваний сопровождается увеличением ее размеров, что получило название зоба или струмы. По распространенности процесса и по внешнему виду железы зоб подразделяется на диффузный, узловатый и смешанный. По гистологической структуре выделяют 2 формы зоба - коллоидный и паренхиматозный. Коллоидный зоб характеризуется накоплением и застоем густого коллоида в полостях фолликулов. IN
  18. Щитовидная железа (проблемы)
    Физическая блокировка Щитовидная железа имеет форму щита и расположена в основании шеи. Гормоны, вырабатываемые этой железой, играют очень важную роль во многих процессах в человеческом организме. Основные проблемы, связанные с этой железой, - ГИПЕРТИРЕОЗ (повышение функции) и ГИПОТИРЕОЗ (недостаточность функции). Эмоциональная блокировка Щитовидная железа связывает физическое тело человека
  19. Заболевания щитовидной железы и беременность
    Анатомия и физиология щитовидной железы Щитовидная железа представляет собой небольшой орган массой 15—20 г, имеет форму бабочки и располагается на шее спереди от трахеи и снизу от гортани. Она состоит из двух долей размером до 4 см в длину и 2,5 см в ширину, соединенных перешейком. Нередко у молодых и худых людей щитовидную железу можно увидеть. Прощупывается она у большинства людей, за
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