B. S. Lozanov
Clinical Center of Endocrinology and Gerontology, Medical University ­ Sofia

Abstract

The heart and vessels are the major target system for thyroid hormones action, invariably responding to hormone excess or insufficiency. Pathogenetic mechanisms giving rise to functional and pathomorphological changes in hyper- and hypothyroidism are multiform. They are determined by the direct and indirect effect of thyroid hormones (TH) on myocardial contractility and sensitivity, as well as on peripheral vascular resistance, induced by their action on gene expressions, synthesis and activity of structural contractile proteins, specific cellular enzymes and vasoactive substances. Their effect on beta-adrenergic stimulation and adenylcyclase system is very important, and under definite conditions ­ on the synthesis of glucose aminoglycans (GAG) in the vascular wall, valvular apparatus and other structures. Clinical expression of cardiovascular disorders in hyper- and hypothyroidism depends on the degree of hormonal excess or deficit, as well as on peripheral response, on tissue TH clearance in cardiovascular structures, respectively. The latter is an individual and age-related entity, determined by a number of endo- and exogenous factors, with the receptor and postreceptor effector systems being the basic ones, including the activity of cellular deiodinase-1, promoting in turn peripheral thyroxin conversion into T3/rT3. The accelerated effects of these systems at myocardial-arterial wall level give rise to cardiovascular manifestations in patients presenting subnormal TSH concentrations against the background of normal serum T3 and T4 levels (the so-called subclinical hyperthyroidism), as well as in clinically manifest forms with predominant cardiac invovement and thyrotoxic cardiomyopathy (CMP) development. There is evidence that in definite cases with autoimmune hyperthyroidism are invoved autoimmune mechanisms with participation of organ-specific antimyocardical antibodies, exerting cytotoxic effect and intensifying the dystrophic myocardial lesions (”thyroid associated autoimmune cardiomyopathy”). Similar data reffering to autoimmune stimulation of the extracellular matrix and valvular apparatus with glycosaminoglycans accumulation explain the thickening and prolapse of the mitral cusps in 33% of Graves’ disease patients. No correlation is found between specific  autoimmune reactions, on the one hand, and thyroid functional status and antithyroid treatment undertaken, on the other.
A number of problems relating to cardiovascular pathology against the background of thyroid disease are still not well enough clarified, notwithstanding the noticeable progress of studies at cellular and molecular level. The development of new specific biochemical, immunologic and functional methods along these lines will certainly contribute to gain better insight into the problems of precise diagnosing and effective treatment of thyriod induced cardiovascular disorders.
 

KEY WORDS: Graves’ disease, cardiomyopathy, hypertension, hypothyroid cardiomyopathy.

H. Bohchelian
Clinic of Endocrinology, Medical University ­ Varna

Abstract

The treatment of diabetic foot complications requires good knowledge and awareness of the risk factors for amputation. The commonest causes giving rise to foot ulcerations are diabetic neuropathy, peripheral vascular disease and deformities. Foot ulcers are classified according to a risk assessment system, and subjected to comprehensive therapeutic approach, including: treatment of the infection and vascular pathology, nonweightbearing with a view to relief pressure, local wound management, permanent adequate metabolic control and training. Successful treatment and primary healing of a foot ulceration mark the beginning of the ensuing compulsory stage ­ preventive health care. All patients with diabetic foot at risk, and particularly those with a previous history of foot ulcers or amputations, necessitate continuous supervision and medical care as a prophylaxis against further relapses.

KEY WORDS: diabetic foot, foot ulceration, risk factors, management.

M. Orbetzova
Clinical Center of Endocrinology and Gerontology, Medical Uhiversity ­ Sofia

Abstract

Prolactin is endowed with a broad spectrum of biological effects, metabolic control inclusive. Presumably, it is a matter of a diabetogenic hormone, but data available concerning its impact on lipid metabolism are scanty. Studies on the aforementioned prolactin effects in humans are very few, and so far there is no evidence whatsoever pointing that the hormone is directly implicated in the pathogenesis of diabetes mellitus. In endogenous hyperprolactinemia states a resistance to insulin action has been documented, explaining its enhanced secretion. It is suggested that in normal conditions prolactin is not diabetogenic, and most probably such an effect may be expressed in subjects with pancreatic beta-cell function impairment. Prolactin alters lipid metabolism, but this effect does not correlate with the degree of overweight, demonstrating in turn that hyperprolactinemia itself is the primary cause of lipid disorders, whereas obesity is merely a secondary aggravating phenomenon. Most likely, diverse factors contribute to the early occurrence of insulin resistance in adipose tissue which is an assumption awaiting further elucidation.

KEY WORDS: prolactin, prolactinoma, carbohydrate metabolism, diabetes mellitus, lipid metabolism, dyslipidemia.

V. Christov, G. Sheinkova
Endocrinology Clinic, Medical University ­ Sofia

Abstract

It is the purpose of the report to assay the effect of Cabergoline used in the treatment of 10 patients with microprolactinoma ­ 9 women and 1 man presenting hyperprolactinemia of 1­8 years longstanding. Prior to treatment and at the end of the 6th month, the following indicators are studied: prolactin, LH, FSH and E2. CT or MRI of the hypophysis are also carried out. In all patients the initial dose is 0,125 mg. At termination of the first month, after prolactin check up examination, the dose of the drug is corrected. As shown by the results, prolactin returns to normal, and is sustained within normal values till the end of the follow-up period. Menstrual cycle recovery and elimination of galactorrhea are clinically observed. Hypophyseal imaging by CT or MRI do not reveal any changes in the size of microadenoma. Cabergoline proves effective at comparatively small median dose, and is well tolerated by the patients.

KEY WORDS: hyperprolactinemia, prolactinoma, Cabergoline.

P. Kamenova, D. Koev, L. Dakovska, G. Kirilov
Clinical Center of Endocrinology and Gerontology, Medical University ­ Sofia

Abstract

Antihypertensive drug therapy in type 2 diabetic patients should be aimed at restoring normal blood pressure, as well as exerting favorable effect on all cardiovascular risk factors. In a randomized non-comparative study, covering 10 type 2 diabetic patients presenting mild-to-moderate hypertension, the effects of 6-week-long treatment with the alpha-blocker Doxazosin on insulin sensitivity, blood glucose control, serum lipids and albuminuria are assayed. At the end of trial period, the average Doxazosin dose amounts to 3,4±2,2 mg/day. Doxazosin significantly decreases mean supine systolic and diastolic blood pressure from 156±11 to 128±9, and from 99±6 to 83±5 mm Hg, respectively (p<0,001). Doxazosin brings about similar and significant reductions in standing systolic and diastolic blood pressure without evidence of orthostatic hypotension. Heart rate remains unchanged. Insulin sensitivity in terms of glucose disposal rate during the last 30 min of the hyperinsulinemic euglycemic glucose clamp test is increased from 2,28±1,19 to 3,78±1,38 mg/kg/min (p<0,02), with a significant rise of insulin sensitivity index from 2,48±1,69 to 4,34±1,19 mg/kg/min per mUI/l x 100 (p<0,05). Baseline and steady state immunoreactive insulin remains unchanged. Mean fasting blood glucose falls significantly from 7,53±1,16 to 6,40±0,99 mmol/l (p<0,05). Serum total cholesterol,  HDL-cholesterol, LDL-cholesterol and triglycerides do not show noteworthy changes. The 24-hour albumin excretion and body weight are not influenced by the treatment. No side effects are registered.
Proceeding from the obtained data the conclusion is drawn that Doxazosin apart from being an effective antihypertensive agent, exerts beneficial effect on other risk factors associated with coronary heart disease, including insulin resistance and hyperglycemia.

KEY WORDS: Doxazosin, type 2 diabetes mellitus, arterial hypertension, insulin sensitivity, cardiovascular risk factors.

A.-M. Borissova, A. Shinkov, R. Kovatcheva, M. Vukov
Clinical Center of Endocrinology and Gerontology, Medical University ­ Sofia
*National Center of Health Information
 

Abstract

For ten years, East European countries have been in economic, social and cultural turmoil. Contemporary postmenopausal women were bred in the post world war II period, spent most of their lives in so-called “developed socialism”, and developed incompatibility with modern lifestyles and concepts. This gave rise to internal conflicts and inability of many women to change rapidly enough. This unfavourable background is further complicated by an additional change ­ the menopause. A total of 627 middle-aged women (range 38­58 y) from administrative and health care institutions in three large cities (Sofia, Burgas, Blagoevgrad) of which 332 postmenopausal and 295 menstruating are covered by the study. All participants undergo free of charge bone mineral density (BMD) measurements and fill in anonymous questionnaire cards. A comparative assessment is done between the groups of menstruating women (n=295), postmenopausal women on HRT (n=32) and postmenopausal women without HRT (n=296). Only 14 women (4,21%) apply HRT for period exceeding one year. This is a method used mainly by married (80%) and divorced (20%) women, while unmarried women and widows, and subjects with secondary education do not use it. There is a significant correlation between a number of parameters of the psychological and sexual status (depression/sexual aversion, depression/change in sexual life, anxiety/change in sexual life, self confidence/sexual thoughts, self confidence/sexual desire, self confidence/orgasm, self confidence/arousal by partner, coping with life/orgasm). Nearly 20% of middle-aged Bulgarian women have depressive thoughts, 50% ­ anxiety and 13% ­ inferiority complex. These findings correlate well with the unfavourable economic situation in the country, unemployment and uncertainty for the future. The inquired women have jobs and adequate background, at the top of their proffesional career and rather emancipated. Probably some of them are the main support in the family which explains the high rate of anxiety among them. Obviously, they rely on themselves, on their own profesional capabilities and social standing. Bulgarian women are reluctant to anwer questions concerning sexual issues. Probably this is attributable to the conflict between proeuropean lifestyle, education and culture, on the hand, and conservatism of the longstanding Balkan traditions and prejudices, on the other. The sexual life of postmenopausal women without HRT is at significant variance from the one in both menstruating and postmenopausal women undergoing HRT.
Conclusion: The psychological and sexual status of Bulgarian women in menopause is changed under the influence of both reduced sex steroids and serious economic, social and cultural crisis in the country.

KEY WORDS: menopause, psychological and sexual status.