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Some accidental overdoses and poisonings could certainly be avoided if individuals were more careful about reading labels on medications and not mixing them with alcohol or other prescription medications without consulting with their health care provider symptoms 8 days past ovulation order trazodone 100 mg. Some of the overdoses are attributed to suicide medicine norco purchase cheap trazodone line, but far more are due strictly to misuse or overuse of prescription or over-the-counter medications. Many of these overdoses occur in those addicted to pain medications such as oxycodone. The overuse and abuse of prescription medications is rampant in the United States. Pain medications, such as the opiate drugs, are the most common ones that are abused. However, other over-the-counter drugs such as loperamide, decongestants, cough suppressants, and antihistamines are also abused. These drugs are generally considered to be safe, but should only be taken as prescribed by the health care provider and/or as noted on the label. The old adage "Read the Label," certainly applies when trying to prevent overdoses, but the individuals also need to "follow the instructions" after reading the label. Source: Associated Press (2016) and Davidson (2016) Copyright 2019 Cengage Learning. They do pro duce increases in muscle strength, lean body mass, and improved performance over periods of time, but the long-term effects are dangerous. The side effects include shrinking of the testes, reduced sperm count, infertility, and baldness in males; and growth of facial hair, changes in menstruation, enlargement of the cli toris, and a deepened voice in females. A spectrum of behaviors is exhibited by people on anabolic steroids: these behaviors range from being somewhat more assertive, to being frankly aggressive, to displaying what is described as "roid rage. Adolescents or preteen children can experience accelerated puberty changes and growth cessation from premature skeletal maturation. These disorders affect the cognitive abilities-the abilities to think, remember, and make judgments by the affected indi vidual. Dementia is common in the elderly; it was called senility in the past and thought to be caused by aging. Dementia is a progressive deterioration of mental abilities due to physical changes in the brain. We now know that dementia is not part of the normal aging process but, rather, is caused by a variety of medical conditions. Factors important in determining whether dementia will occur in an individual include nutritional status, family history, chronic diseases, and general state of health. An affected individual might lose items, get lost when driving even in familiar areas, get confused in conversations, and lose the ability to perform common tasks such as balancing a checkbook. Symptoms often develop gradually and show a progressive deterioration of cognitive or mental abilities, including severe memory loss, disorientation, impaired judgment, and the inability to learn new thorough medical, physical, and neurologic examination. The American Psychiatric Association has established two criteria to support the diagnosis of dementia. The second is the loss of one of the following functions: language, motor activity, recognition, and executive function (unable to plan, organize, or think abstractly). These include correcting drug doses, ensuring that prescribed medications are being taken correctly, withdrawing misused drugs, treating depression and other medical conditions, and ensuring proper nutrition and hydration. Prompt and effective treatment of the cause often reverses the symptoms of delirium. Activities such as reading, playing musical instruments, dancing, playing board games, and doing puzzles are beneficial. Delirium is not a disease but a clinical syndrome, or set of symptoms, that might result from a disease. Thorough assessment is necessary to distinguish it from other psychiatric disorders. Deliriums commonly affect 1 in 10 hospitalized patients and as many as 80% of those in intensive care units. Delirium is more common in the elderly and, although it is not a disease in and of itself, those who have it usually do not do as well as those with the same illness who do not have delirium.

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If poisoning does occur symptoms of colon cancer quality 100mg trazodone, the ensuing clinical syndrome may be distinctive; for example 3 medications that cannot be crushed buy trazodone 100 mg on line, fixed dilated pupils, exaggerated tendon reflexes, extensor plantar responses, depressed respiration, and cardiac tachyarrhythmias suggest tricyclic antidepressant poisoning; anaemia, constipation, colic, and motor nerve palsies are indicative of lead poisoning. However, with many psychotropic medicines there may only be nonspecific central nervous depression, respiratory impairment, and hypotension. It is usually accidental in small children, but in adults it is almost invariably deliberate (deliberate self-harm) or, rarely, it may be with homicidal intent. Occupational poisoning is common in developing countries and continues to occur in the developed world. The medical approach to poisoning should never be confined to the poison and its effects. All the circumstances surrounding the episode must be considered, especially in cases where litigation may follow It is therefore important that the doctor concerned, having instituted any necessary life-saving measures, should take a careful history, retain all pertinent evidence such as a suicide note and biological specimens, make a meticulous record of symptoms, signs, progress, and outcome, and remember issues of confidentiality. Since deliberate self-harm is a risk factor for further such episodes, approximately 25% of these cases occur in the same patient group. Self-harm in women and men is somewhat different, and other than young children, mortality data for out-of-hospital deaths show that men are more likely to succeed in killing themselves than women. The severity of poisoning depends on the quantities ingested, but hospital statistics do not provide adequate data to assess this. Mortality data provide information on the relative toxicity of different compounds if it can be expressed per head of population exposed. This is a technique that is best used for assessing the toxicity of prescription medicines; it is much less easily applied to chemicals and household products when measures of availability are not so readily obtained. Few have formal psychiatric diagnoses, such as depression or psychosis, or are truly suicidal, since the incident is impulsive rather than planned. Mortality is often higher in older age groups where overdose planning has been more careful, and has involved prescription medicines which typically are more toxic than over-the-counter preparations taken by younger patients. Impulsive behaviour is often associated with ingestion of alcohol and as many as two-thirds of men, and nearly one-half of women, take alcohol in association with an overdose. In many cases of self-harm more than one drug is included in the cocktail, making clinical management more complex, particularly if two or more agents acting on the same body system are involved. This applies particularly to drugs acting on the brain, kidney, and cardiovascular system. The increasing worldwide use of drugs of abuse has also influenced patterns of poisoning, and many cases of poisoning in this population result from variations in quality of supply or experimentation. Prescription medicines are used in most self-harm episodes in the United Kingdom, the rest of Europe, North America, and countries in the developed world and their availability, therefore, influences the numbers of patients seen. The diagnoses for which the drug is used will also affect how often it is taken as a self-harm agent. Thus, self-harm with drugs for peptic ulcer disease is very uncommon, whereas overdose with antidepressants is much more frequent. In the United Kingdom, paracetamol contributes approximately onethird of all poisonings seen in hospitals but, although common in North America and other parts of Western Europe, the proportion of cases is lower. In developing countries, such as Sri Lanka and India, drugs are much more expensive and the agents ingested are either plants, such as yellow oleander, or the widely available pesticides. Consequently, although the numbers of patients self-harming per head of population are quite similar, the mortality rates in Sri Lanka are orders of magnitude higher than in Western Europe. Many children with relatively mild features will be managed at home or in emergency departments, where national statistical data are not routinely collected, and so in this population national statistics are unreliable, except for agents that cause death. Deaths in children are usually attributable to inappropriate storage, including toxic pharmaceuticals, such as digoxin and quinine, household products and, increasingly, drugs of abuse. Herbicide exposures are common in agricultural countries where these materials are stored in the home. Child-resistant containers have reduced poisoning rates in children, but tragedies still occur. Diagnosis Diagnosis of acute poisoning requires that the doctor not only establish that exposure to a poison has occurred, but also its chemical composition and the route and magnitude of exposure, so that the features likely to develop can be anticipated and risk assessed. However, in acute poisoning, there are many obstacles to establishing the information required. Young children may not be able to give a history; adults are often unreliable; physical signs are rarely diagnostic; circumstantial evidence may be unavailable, tentative, or misleading; and laboratory diagnosis is rarely comprehensive.

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While an association between higher weight and contraceptive failure has been reported [30 treatment broken toe buy trazodone with visa,31] medications safe for dogs buy trazodone 100 mg fast delivery, it is hard to distinguish between method failure and user failure and so the effect of weight on failure rates has been suggested to be a reflection of issues of compliance [32]. A study that examined risk factors for failure of two types of oral emergency contraception (levonorgestrel and ulipristal acetate) found that failure rates were significantly higher among women with obesity and that this was more marked for women receiving levonorgestrel [33]. Pharmacokinetic studies have shown that the emergency contraceptive dose of levonorgestrel takes a longer time to reach steady-state levels in women with obesity and that this is not observed with ulipristal acetate [34]. The authors suggested that this could be a possible mechanism for reduced efficacy of emergency contraception in women with obesity. The authors of this study suggested that this may be because these men might feel less able to negotiate safe sex and may be less well placed to be selective about sexual partners. From a public health perspective, we need to continue to pursue effective strategies (prevention and cure) to tackle obesity. Health-care professionals should also be encouraged to have sensitive discussions around weight loss and be able to signpost individuals to appropriate services for weight reduction, since these may ultimately prove effective and result in an improved quality of both physical and sexual health. Conclusion In addition to the physical problems caused by obesity, there is evidence that obesity negatively impacts on sexual health. Clearly, however, the relative contribution of social (stigma of obesity), psychological (low self-esteem), and physical consequences of obesity upon sexual health is difficult to disentangle (Table 4. There is evidence that emergency hormonal contraception may be less effective in women with obesity. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Successful weight loss following obesity surgery and the perceived liability of morbid obesity. Association between comorbidities and female sexual dysfunction: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal3). Targeting sexual health services in primary care: a systematic review of the psychosocial correlates of adverse sexual health outcomes reported in probability surveys of women of reproductive age. The relationship between body mass index and unintended pregnancy: results from the 2002 National Survey of Family Growth. The association between body weight, unintended pregnancy resulting in a livebirth, and contraception at the time of conception. Obesity and oral contraceptive failure: findings from the 2002 National Survey of Family growth. Ovarian suppression in normal-weight and obese women during oral contraceptive use. Pharmacokinetics of levonorgestrel and ulipristal acetate emergency contraception in women with normal and obese body mass index. The prevalence of obesity has doubled over the past 30 years with 15% of women worldwide classified as obese as of 2014. More worrying is the data that shows more than 42 million children under the age of 5 years overweight as of 2013 [1]. Not surprisingly, the prevalence of obesity in pregnancy is rising exponentially, with obesity rates of around 32% reported in women between 20 and 39 years of age [2]. This is the age-group where apart from obesity, pregnancy can be complicated by diabetes and hypertension. These "three musketeers" are a devastating combination for women in pregnancy leading to a wide array of poor obstetric and neonatal outcomes. In addition, obesity in pregnancy also poses a serious challenge to the skills of the obstetrician, anesthetist, and midwives. Obese women reported less contraceptive usage, more contraceptive failure, and lower intake of preconceptional folic acid, which can greatly compromise prepregnancy and pregnancy care [3]. Prevention of unwanted pregnancy in obese women is, therefore, a major priority for health-care professionals. The aim of this chapter is to review the various contraceptive options available to the obese woman. Knowledge of such contraceptive options may lead to a reduction of unwanted pregnancies and support women in their quest for a wellplanned pregnancy. Maternal obesity also contributes to adverse fetal outcomes, including macrosomia [14], shoulder dystocia [15], infant mortality [16], and predisposition to obesity later in life [17]. A systematic review of reviews [18] confirmed the above mentioned findings, emphasizing the need for obese women to lose weight before they conceive and for health-care professionals to support obese women in this endeavor.

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The affected individual usually realizes that the phobia is irrational symptoms of the flu generic trazodone 100mg on line, but is still unable to control the fear medicine river animal hospital trazodone 100 mg for sale. Compulsion is a repetitive act the affected individual is unable to resist performing. Behavior becomes ritualistic, and thoughts or attempts to stop the thought or action bring about extreme anxiety. This behavior becomes very time-consuming, usually taking more than an hour a day, and can become so disruptive that the individual is unable to perform daily activities or hold a job. Examples of compulsive activities include handwashing, cleaning objects, checking an object, and locking and unlocking locks. This disorder is a new addition to anxiety disorders and was first observed frequently in Vietnam veterans. The feelings and fears associ ated with the trauma do not normally diminish with the passing of time. Affected individuals often relive this trauma for weeks, months, or years in painful recollections or dreams and frequently go to extremes to avoid any reminder of the trauma. Symptoms include: Flashbacks with the individual reliving the traumatic event Difficulty developing and maintaining relationships Irritability and agitation Depression Social withdrawal Drug dependency Diagnosis. Hypnosis, stress reduction, relaxation therapy, physical exercise, and biofeedback can be used to treat the condition, depending on severity and cause. These individuals have an astounding knowledge of medical conditions and are constantly watchful of symptoms. Hypochondriacs have an unrealistic fear that they are ill, despite medical assurance to the contrary. Affected individuals have difficulty establishing and maintaining relationships because so much of their energy and conversation revolve around their perceived illnesses. Pain disorder can occur at any age but commonly occurs in adolescent and young females. This disorder is characterized by pain that does not have a physiologic cause or, if a cause is discovered, the pain is greater than normally expected. Malingering is the fictitious display of symptoms to gain financial or personal reward. Diagnosis is often difficult because many of the symptoms are subjective and difficult to disprove. Munchausen syndrome is a group of disorders in which the affected individuals simulate illness for no other apparent reason than to receive treatment. Often, the individuals will go to extremes to present false tests, for example, scratching or cutting themselves to add blood to urine specimens. An affected person also might self-inject a variety of substances into the blood or tissues to cause an illness. Generally, this individual has an extensive knowledge of diseases, medical treatments, terminology, and hospital routine. Affected individuals often present to emergency departments with reports of a variety of symptoms. When testing does not support the stated symptoms, the individual often reports different symptoms. There is usually a hi story of repeated hospitalizations with undetermined diagnosis. When the behavior is discovered, the confronted individual often becomes hostile and seeks attention at a different facility. Munchausen by proxy is the same disorder except the parent projects the disorder onto a child. The parent might inject the child or otherwise cause illness and then present the child for treatment. Somatoform (somato = body) disorders are characterized by physical symptoms that lead one to believe in a physical disease, but no organic or physiologic cause can be found.

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As we spend most of our lives indoors medications heart disease order trazodone 100mg, indoor air quality is clearly equally important treatment 6th feb cardiff order trazodone 100 mg amex. In such settings tobacco smoke becomes the most important source of indoor pollutant, exposure to which has been shown extensively to impart adverse health effects. While there has been ample evidence to suggest the global burden of mortality and morbidity associated with household air pollution is substantial and comparable to ambient air pollution, it has not received adequate attention until recently. At present the extent of the health effect(s) of these pollutants, alone or in combination, are a continuing matter for research and debate. Although acute effects have often been deemed to be small, as more studies of health effects of long-term exposure are undertaken, the true picture of the burden due to air pollution is beginning to unravel. Given the loose definition, it is not surprising that a long list of substances could be defined as air pollutants. In the urban environment, the concentration of airborne pollutants is usually higher outdoors compared to indoors because of the high volume of vehicular emissions. However, improved thermal insulation and the use of air conditioning systems in modern dwellings may also facilitate the accumulation of indoor pollutants, particularly when people smoke in their homes. Pollutants can also be grouped by their physical properties, often by their state and size. Secondary: Pollutants that form in the air as a result of chemical reactions with other pollutants and gases Sources: Combustion, cooking, heating, smoking, particle resuspension, building materials, air conditioning, consumer products, biological agents ii. Sources: Industrial, commercial, transportation, agricultural, natural, transboundary ii. One such example is ground (tropospheric) level ozone (as opposed to stratospheric ozone, which is naturally occurring), formed by chemical reactions of oxides of nitrogen and hydrocarbons in the presence of sunlight. Ozone is one of the main constituents of the photochemical smog, which is typical in cities with many motor vehicles on warm sunny days. Ultrafine particles are less than 100 nm in size, and may even penetrate into the systemic circulation. Measurement of a health effect the main problem in determining health effects of individual air pollutants is that in real life they are never experienced in isolation. There are multiple potential interactions, not only with other air pollutants, but with other factors such as weather conditions (as in the 1952 London smog), levels of airborne allergen, the presence of a respiratory tract infection, exercise, diet, socioeconomic status, and actively or passively inhaled cigarette smoke. Some health effects may also be attributed to multiple risk factors at a time and hence making determination of specific, pollutant-induced health effects difficult. There are three main ways whereby a health effect can be assessed: animal studies, challenge studies in humans, and by epidemiological studies (including cross-sectional, time series, case-crossover, and cohort studies). Each has their problems but when determining national ambient air quality standards all available types of data may be taken into consideration. Although individual risks are relatively easily measurable in the workplace, when considering ambient airborne pollution individual risk and public health load has not been very well characterized to date. This is partly because the health effects of outdoor air pollution are considerably less than the risks of active cigarette smoking or the risks of other well-recognized aetiological factors Moreover, potential sources of confounding, primarily in terms of socioeconomic status and cigarette smoking might have affected the interpretation of the health effects of air pollution. Recent evidence suggests long-term exposure to air pollution, especially fine particulate, could also adversely affect other outcomes such as diabetes, impaired cognitive function, preterm birth, and lower birthweight. More importantly, it is extremely difficult to ascertain and quantify the level and duration of exposure to airborne pollutant at both population and individual levels with high accuracy and precision. Coexposure at the same time to another pollutant will likely affect any physiological response as will the presence of cofactors such as age, individual susceptibility (presence of comorbidities, concurrent respiratory tract infection, degree of bronchial responsiveness), smoking, physical activity (which increases effective lung dose due to enhanced ventilation) or diet. Such variations within and between individuals have added the complexity in interpreting the findings from previous literature. Although health effects of air pollution could be at times difficult to assess and to ascertain from observational studies, interventions (often associated with pollution abatement legislations) have provided indirect evidence to support the link between air pollution and adverse health outcomes. Associations between improved air quality and reduction in mortality have also been reported following the reduction of sulphur content of fuel in Hong Kong in 1990. On the other hand, conflicting findings have been reported in studies investigating the effect of low emission/congestion charging zones on pollutant levels. Nevertheless, a study in Rome estimated that residents living near main roads have gained 3. Transient changes in air quality have also been demonstrated to have measurable population health benefits.

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Comparing effects of a low-energy diet and a highprotein low-fat diet on sexual and endothelial function treatment for vertigo buy cheap trazodone 100mg on-line, urinary tract symptoms medicine names buy genuine trazodone on-line, and inflammation in obese diabetic men. Managing erectile dysfunction in hypertension: the effects of a continuous training programme on biomarker of inflammation. Tadalafil and modifications in peak systolic velocity (Doppler spectrum dynamic analysis) in the cavernosal arteries of patients with type 2 diabetes after continuous tadalafil treatment. Relationship between chronic tadalafil administration and improvement of endothelial function in men with erectile dysfunction: a pilot study. Switching from long-term treatment with selfinjections to oral sildenafil in diabetic patients with severe erectile dysfunction. Clinical reliability of multi-drug intracavernous vasoactive pharmacotherapy for diabetic impotence. Penile prosthesis implantation for the treatment for male erectile dysfunction: clinical outcomes and lessons learnt after 955 procedures. Effects of testosterone on type 2 diabetes and components of the metabolic syndrome. The effects of testosterone on risk factors for, and the mediators of, the atherosclerotic process. The hypogonadal-obesity cycle: role of aromatase in modulating the testosterone-estradiol shunt-a major factor in the genesis of morbid obesity. Chapter 13 Male obesity-impact on semen quality Vanessa Kay1 and Sarah Martins da Silva2 1 Assisted Conception Unit, Ninewells Hospital, Dundee, United Kingdom, 2Reproductive and Developmental Biology, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom Introduction Male infertility is the commonest cause of infertility, underlying or contributing to at least 40% of all cases of infertility [1]. Therefore it is important to identify modifiable risk factors for male fertility, to enable both preventative and curative treatments for this condition. In Europe the International Obesity Task Force has indicated that obesity rates in adult men range from 10% to 27% [4]. Notably, Scotland has one of the highest rates of obesity among developed countries. Recent data has shown that Scottish men are significantly more likely to be overweight or obese (68%) in comparison to women (61%), with female prevalence remaining static since 2008 [5]. The adverse influence of obesity on various aspects of female reproduction and fertility has been acknowledged for some time [6], and management guidelines are now available [7]. More recently, data regarding male obesity and infertility has been accumulating [8]. One could argue that the association between male obesity and infertility could be due to confounding factors such as male age, diet, Obesity and Gynecology. Impact on semen quality Semen quality is accepted as a surrogate marker for male fertility, with established reference ranges [16]. Although the majority of obese men have normal semen parameters, a correlation between poor semen quality and obesity has been recognized for some time [17], with recent largescale data (4440 men) confirming statistically significant relationships between obesity and semen analysis characteristics [12]. This finding was supported in a review by Mah and Wittert [20] who concluded that obese men have reduced sperm concentration and total sperm count, compared to lean men, but with motility and morphology unaffected. Morphology evaluation is somewhat controversial, not least because it is influenced by the subjectiveness of the observer and lacks objective measurement. Perhaps, unsurprisingly it is this area of diagnostic semen analysis where studies have found quite conflicting effects of obesity. The findings of this study have been confirmed in a retrospective study of 526 infertile men in which the incidence of oligozoospermia and low progressive motile sperm concentration was higher in overweight and obese men compared with those of normal weight [28] and later confirmed by Sekhavat and Moein who studied 852 healthy men [29]. First, a study Combined semen parameters A few studies have looked at combined measures of semen parameters. It is important to note that most obese men have been shown to have normal semen quality and fertility. The relationship between sperm quality and obesity is still not clearly understood and is complex with various factors involved.

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Clomiphene resistance is attributed to several hormonal and clinical characteristics of the women medicine buy trazodone 100 mg fast delivery. Especially treatment kidney cancer purchase 100mg trazodone mastercard, women with less-reduced insulin sensitivity had a higher possibility of ovulating on clomiphene treatment [90], while obesity had a negative impact on the treatment outcome with clomiphene [91]. Such women may need higher dosages of clomiphene even up to 250 mg/day, although the evidence is limited to retrospective data [92]. These compounds inhibit the action of the enzyme aromatase, which converts androgens into estrogens. Consequently, the reduced production of estrogens and the reduced circulating levels of these steroids lead to the attenuation of the negative feedback and the increase in the secretion of gonadotrophins from the pituitary. Letrozole is one of the third-generation aromatase inhibitors used more extensively than others for the treatment of infertility. It should be noted, however, that letrozole is still considered an "offlabel" medication for infertility treatment due to possible teratogenic effects in pregnancy, although this has been debated [83,102]. It is advisable, therefore, to discuss with the patients the possible risks and benefits. Both protocols are equally effective in terms of pregnancy rate, although with the step-up protocol higher monofollicular development and lower hyperstimulation are achieved [105]. The treatment is monitored only by ultrasound scans of the ovaries, while estradiol measurement is not required. In the same study, significantly higher doses of gonadotrophins were required in the group of the obese than in the group of the lean women, a finding that was confirmed in a subsequent study [110]. However, due to a rather complicated prediction model based on a mathematical equation, such an approach has not been proven reliably effective. Obesity in polycystic ovary syndrome and infertility Chapter 3 29 Retrospective data have shown high ovulation and pregnancy rates [116]. Ovarian drilling can be also performed by fertiloscopy, which provides as good results as laparoscopy, but experience is needed because the risk of complications is greater [124]. Metformin is the main representative and has been used more extensively than other compounds with similar actions. Treatment with metformin would be expected to improve insulin sensitivity and the metabolic and reproductive functions. Nevertheless, metformin administration over a period of 6 months in the context of a diet and lifestyle changes program was not better than placebo regarding body-weight reduction [134]. A more recent study, however, has shown that with metformin, the weight loss was greater than that with lifestyle changes, although there was a high dropout rate [136]. Understanding variation in prevalence estimates of polycystic ovary syndrome: a systematic review and meta-analysis. Body mass index and ovarian function are associated with endocrine and metabolic abnormalities in women with hyperandrogenic syndrome. Abdominal fat quantity and distribution in women with polycystic ovary syndrome and extent of its relation to insulin resistance. A prospective study of the prevalence of the polycystic ovary syndrome in unselected Caucasian women from Spain. Differences in clinical and endocrine features between obese and non-obese subjects with polycystic ovary syndrome: an analysis of 263 consecutive cases. Characteristics of obesity in polycystic ovary syndrome: etiology, treatment, and genetics. The independent effects of polycystic ovary syndrome and obesity on serum concentrations of gonadotrophins and sex steroids in premenopausal women. Ovarian control of pituitary sensitivity of luteinizing hormone secretion to gonadotropin-releasing hormone in women with the polycystic ovary syndrome. Polycystic ovarian syndrome: evidence that flutamide restores sensitivity of the gonadotropin-releasing hormone pulse generator to inhibition by estradiol and progesterone. Inverse relationship between luteinizing hormone and body mass index in polycystic ovarian syndrome: investigation of hypothalamic and pituitary contributions. Evidence for insulin suppression of baseline luteinizing hormone in women with polycystic ovarian syndrome and normal women. Serum leptin levels in women with polycystic ovary syndrome: the role of insulin resistance/ hyperinsulinemia.