Group A streptococcus: is there a genital carrier state in women following infection?

Group A streptococcus (GAS) is a rare but serious cause of postpartum and gynecological infections. There are no follow-up or prophylaxis guidelines for women with previous GAS genital infection. We aimed to evaluate the incidence of long-term gynecological carrier state in patients with a history of genital GAS infection. This is a prospective study of women who had a genital GAS infection and were followed for 1 year from the date of isolation. Cultures were obtained every 3-4 months. As a control group, women with no previously documented GAS infection were screened for GAS. Twenty-five women with a previous GAS infection participated in the study. Two of the 25 patients had positive vaginal GAS cultures during follow-up, giving a carrier rate of 8 %. Four hundred and thirty-six women participated in the control group; none was a carrier of GAS (p < 0.003). We found that common gynecological procedures were occasionally associated with invasive GAS infection. A significant rate of carriers was found among women with previous GAS genital infection. Common office procedures can be related to severe GAS infection. Consideration should be given to screening women with previous GAS infection prior to invasive as well as semi-invasive gynecological or obstetric procedures.

Long-term efficacy of Paula method as compared with pelvic floor muscle training for stress urinary incontinence in women: a 6-month follow-up.

PURPOSE: The purpose of this study was to examine the long-term efficacy of an exercise regimen based on circular muscle strengthening (Paula method) as opposed to pelvic floor muscle training (PFMT) on stress urinary incontinence symptoms at 6 months postintervention. SUBJECTS AND SETTING: Of 240 women who had initially participated in a randomized clinical trial, 143 women suffering from stress urinary incontinence participated in this follow-up study. METHODS: Subjects participated in a randomized controlled clinical trial comparing 2 exercise programs (12 private Paula lessons vs 6 group PFMT lessons) over a 12-week period. Of these, 143 women took part in the follow-up study: 64 from the Paula group and 79 from the PFMT group. Six-month follow-up data were gathered via telephone interviews. RESULTS: No significant deterioration in stress urinary incontinence symptoms occurred 6 months after completion of the interventions in either group. We found a statistically significant difference between the groups with regard to reported frequency of urinary leakage; 25 of subjects (39.7%) allocated to the Paula method reported a low frequency rate of incontinence episodes upon completion of the study as compared to 18 (22.8%) in the PFMT group (P = .03). Forty-nine of the 64 women in the Paula group (76.6%) and 62 of the 79 women in the PFMT group (78.5%) reported that they continued exercising 6 months after completion of the trial (P = .8). CONCLUSIONS: Both intervention methods reduced frequency of urinary incontinence over a 6-month period. Long-term adherence was similar in both groups. Pelvic floor muscle training was associated with fewer sessions and decreased cost and fewer lessons needed as compared with the Paula method. Nevertheless, results also suggest that the Paula method achieves a lower frequency of urinary leakage than PFMT.

Sex differences in risk factors for coronary artery disease and stroke in men and women aged 45-65†years.

BACKGROUND: Coronary artery disease (CAD) and stroke both result from atherosclerosis. Risk factor profiles for CAD and stroke have been reported to differ between middle-aged men and women. OBJECTIVE: To compare, for men and women aged 45-65 years, between risk factor profiles for CAD and stroke. METHODS: This is a retrospective study based on the medical records of 179 women and 270 men diagnosed with CAD, and 114 women and 190 men diagnosed with stroke, hospitalised in one of two medical centres in Jerusalem. We assessed and compared the number of metabolic risk factors (diabetes, hypertension and hypercholesterolaemia) presenting among men and women between the CAD and stroke groups. RESULTS: Among patients with CAD, significantly more women than men presented with diabetes, hypertension and hypercholesterolaemia. In contrast, no statistically significant differences were observed between genders in the prevalence of diabetes, hypertension and hypercholesterolaemia among the stroke patients. Hypertension was more prevalent in both men and women among stroke patients than CAD patients. In the stroke group, 29.1% of the women compared with 14.2% of the men presented with the three metabolic risk factors investigated. CONCLUSIONS: In a middle-aged population, CAD risk factor profiles differed between genders while stroke risk factor profiles did not.

Three-dimensional transperineal ultrasound findings associated with anal incontinence after intrapartum sphincter tears in primiparous women.

OBJECTIVE: Three-dimensional transperineal sonography (3D-TPS) performed in women following third- or fourth-degree intrapartum tears repaired with the overlapping technique demonstrates characteristic signs. The aim of this study was to investigate the correlation of these signs with clinical complaints of incontinence. METHODS: This was a prospective observational study. Sixty primiparous women underwent 3D-TPS 3-42 (mean, 10.6) months after surgical repair of third- or fourth-degree postpartum sphincter tears with the overlapping technique and were evaluated for clinical degree of incontinence using the St Mark's Incontinence Score (SMIS) questionnaire. The following signs were assessed on 3D-TPS: interruption of the internal anal sphincter or external anal sphincter, 'half moon' sign, changes in the mucosal folds and thickening of the external anal sphincter in the area of sphincter repair. As a comparison group, 27 primiparous women after normal vaginal delivery, without clinically recognized anal sphincter tears, were evaluated similarly, 3-37 (mean, 9.9) months postpartum. RESULTS: Abnormal sonographic signs were apparent in 35 (58.3%) of 60 women in the study group, and 39 (65%) of 60 had some clinical complaints of incontinence 3-42 months after delivery, most of a mild degree. Higher SMIS results were found in women of the study group than in those of the comparison group (mean (SD) 2.80 (0.481) vs. 1.15 (0.365); P = 0.018). The rates of incontinence were similar between the women in the study group with normal ultrasound findings and the women in the comparison group (9/25 vs. 10/27; relative risk (RR) = 0.97, 95% CI, 0.47-1.97). CONCLUSIONS: Sonographic signs of anal sphincter tear and repair had disappeared at follow-up examination in almost half of the patients, and therefore this examination should be deferred from the early postpartum period. A substantial proportion of women report some complaint of incontinence after sphincter repair, most of a slight degree. Such complaints are associated with abnormal 3D-TPS findings at follow up, while in women with a normal 3D-TPS scan the rate of incontinence complaints is similar to that in women after normal delivery.

Concordance between one-hour pad test and subjective assessment of stress incontinence.

OBJECTIVES: To examine the concordance among the 1-hour pad test results, subjective questions regarding incontinence, and a quality-of-life questionnaire to assess the role of the pad test as a noninvasive measurement tool in clinical trials. The 1-hour nonstandard pad test is one of several quantitative tools used to measure urinary incontinence; however, its utility has been questioned. METHODS: The study subjects were women participating in 2 clinical trials evaluating noninvasive interventions: circular muscle exercises versus pelvic floor muscle training for urinary incontinence. The quantity of urinary leakage according to the pad test and questions regarding subjective urinary leakage from the quality-of-life questionnaire were evaluated for all study subjects combined and in subgroups. RESULTS: A total of 731 clinical pad tests were evaluated from the 2 trials. Significant associations were found between several questions regarding subjective leakage and the pad test results in the study subgroups. A significant correlation was seen between the pad test results and the quality-of-life questionnaire scores (r = 0.14 before intervention and r = 0.42 after intervention in the combined studies; P < .05). CONCLUSIONS: The 1-hour pad test demonstrated concordance with subjective assessment tools for urinary incontinence and should be considered a part of the armamentarium for assessing the severity of this condition.

Blood mononuclear cell gene expression signature of postpartum depression.

In sorrow thou shalt bring forth children (Genesis 3:16) seems as relevant today, with one of seven mothers afflicted by a depressive episode, constituting the most common medical complication after delivery. Why mothers are variably affected by mood symptoms postpartum remains unclear, and the pathogenesis and early molecular indicators of this divergent outcome have not been described. We applied a case-control design comparing differential global gene expression profiles in blood mononuclear cells sampled shortly after delivery at the time of inception of postpartum depression (PD). Nine antidepressant naive mothers showing high depressive scores and developing a persisting major depressive episode with postpartum onset were compared with 10 mothers showing low depressive scores and no depressive symptoms on prospective follow-up. A distinctive gene expression signature was observed after delivery among mothers with an emergent PD, with a significant overabundance of transcripts showing a high-fold differential expression between groups, and correlating with depressive symptom severity among all mothers. Early expression signatures correctly classified the majority of PD patients and controls. Those developing persisting PD exhibit a relative downregulation of transcription after delivery, with differential immune activation, and decreased transcriptional engagement in cell proliferation, and DNA replication and repair processes. Our data provide initial evidence indicating that blood cells sampled shortly after delivery may harbor valuable prognostic information for identifying the onset of persisting PD. Some of the informative transcripts and pathways may be implicated in the differential vulnerability that underlies depression pathogenesis.

Randomized trial of circular muscle versus pelvic floor training for stress urinary incontinence in women.

BACKGROUND: Conservative management, such as pelvic floor muscle training (PMFT), is commonly recommended as first-line therapy for women with stress urinary incontinence (SUI). METHODS: We randomly assigned 245 women with SUI to 12 weeks of circular muscle exercises (Paula method) or PMFT in order to assess whether these approaches are equivalent. End points after 12 weeks included urinary leak as measured by a 1-hour pad test, subjective assessment of incontinence, and quality of life (QOL). Cure was defined as urinary leakage of <1 g. RESULTS: The mean decrease in urinary leakage was 7.9 g (SD 12.1) among women in the Paula group and 8.9 g (SD 18.2) in the PFMT group (90% confidence interval [CI] of between-group difference was -4.68 g to 3.0 g). This did not meet the prespecified criterion for equivalence. There were 15.2% (p = 0.04) more cures in those randomized to the Paula method. Improvement in subjective urinary complaints and QOL was observed in both groups. The study was limited by a dropout rate of 26.6%. CONCLUSIONS: Both methods are efficacious in women with SUI. The results suggest superiority of the Paula method in terms of cure rate.

The effect of hormone replacement therapy on cognitive function in post-menopausal women.

BACKGROUND: Despite interest in causes of dementia in older persons, particularly in post-menopausal women, it is unclear whether hormone replacement therapy (HRT) is a risk factor. AIM: To assess cognitive function in post-menopausal women with high educational status receiving HRT, compared to non-users. DESIGN: Cognitive functioning was assessed with in women aged 55-60 years with at least university-level education, using the Mindstreams system, a computerized cognitive battery with multiple domains. RESULTS: Of 165 women meeting the inclusion/exclusion criteria, 82 women (49.7%) declined participation. Of the remaining 83, 40 (48.2%) had never received HRT; the remainder was divided into women receiving 5-9 years HRT (n = 29)versus those with >or=10 years HRT (n = 11). There were no statistically significant differences between HRT users and non-users in global scores or sub-domains of cognitive functioning, and no difference between those women receiving HRT for 5-9 years vs. >or=10 years. DISCUSSIONS: Long-term HRT does not appear to impair cognitive functioning in highly-educated women. Recommendations regarding post-menopausal HRT should be made on an individual basis.

Fetal cardiac ventricle volumetry in the second half of gestation assessed by 4D ultrasound using STIC combined with inversion mode.

OBJECTIVE: Quantification of fetal heart ventricle volume can aid in the evaluation of functional and anatomical aspects of congenital heart disease. The aim of this study was to establish nomograms for ventricular volume using three-dimensional (3D) inversion mode ultrasonography with the spatio-temporal image correlation (STIC) modality and to calculate ejection fraction and stroke volume. METHODS: The fetal heart was scanned using the STIC modality, during fetal quiescence with abdomen uppermost, at an angle of 30-50 degrees , without color Doppler flow mapping. In post-processing, starting with the classic four-chamber view plane in the A-frame, the reference point was moved to the center of the ventricle. The operator used the edit volume followed by Virtual Organ Computer-aided AnaLysis (VOCAL) mode options; in manual trace the VOCAL settings were set to 15 degrees . The trace was drawn and included the myocardium; inversion mode thresholding provided the volume of the intraventricular (anechoic) voxels within the region of interest. The total volume and the intraventricular volume were displayed. The process was repeated for right (R) and left (L) ventricles at end diastole (EDV) and end systole (ESV). The stroke volume (SV = EDV - ESV) and ejection fraction (EF = SV/EDV) were calculated from these measurements. Intraclass correlation was used to evaluate intra- and interobserver agreement. RESULTS: One hundred fetuses ranging from 20 + 5 to 40 + 0 gestational weeks were included in the study. In addition, six fetuses diagnosed during the study period with a cardiac anomaly were examined and their ventricular volumes compared with those of the main study group. LEDV ranged from a mean of 0.53 cm(3) at midgestation to a mean of 3.96 cm(3) at term. LESV ranged from a mean of 0.17 cm(3) at midgestation to 1.56 cm(3) at term. REDV ranged from a mean of 0.68 cm(3) at midgestation to a mean of 5.44 cm(3) at term. RESV ranged from a mean of 0.26 cm(3) at midgestation to 2.29 cm(3) at term. Total stroke volume ranged from a mean of 0.78 cm(3) at midgestation to a mean of 5.5 cm(3) at term. The mean right : left ventricle ratio was 1.4, and left ejection fraction ranged from 42.5 to 86% in these fetuses. Nomograms were created for RESV, LESV, REDV, LEDV and total stroke volumes vs. estimated fetal weight and gestational age. Intra- and interobserver agreement reached 96%. CONCLUSIONS: 3D inversion mode sonography combined with STIC represents a simple and reproducible method for estimating fetal cardiac ventricle volume. This innovative methodology may add to overall evaluation of cardiac volume and function, and improve our understanding of normal and abnormal cardiac structure, as well as the severity and prognosis of cardiac lesions.

Postpartum evaluation of the anal sphincter by transperineal three-dimensional ultrasound in primiparous women after vaginal delivery and following surgical repair of third-degree tears by the overlapping technique.

OBJECTIVE: Intrapartum damage to the anal sphincter is an important factor in fecal incontinence. Recognized lacerations occur in 0.36-8.4% of vaginal deliveries, and occult sphincter damage in up to 35% of primiparous women. We examined the role of three-dimensional transperineal ultrasound (3DTUS) in the evaluation of the anal sphincter in primiparous women after vaginal delivery and after surgical repair of third-degree intrapartum tears by the overlapping technique. METHODS: During 2004-2005 139 primiparous women without clinically recognized third- to fourth-degree anal sphincter tears were prospectively studied 24-72 h postpartum (Group 1) and 13 primiparous women were examined 48 h to 4 months following surgical repair of third-degree tears with the overlapping technique (Group 2). A 3D 5-9-MHz transvaginal probe was placed in the area of the fourchette and perineal body in transverse and sagittal planes and 2-4 volumes were stored. The parameters studied were: examination duration; continuity of the internal and external sphincters; occult sphincter damage; internal sphincter and external sphincter width-measured 1.5 cm from the distal margin of the anus-at the '12, 3, 6 and 9 o'clock positions'; length of the posterior internal sphincter. RESULTS: Scanning was possible in all women and the stored volumes were adequate in 127/139 (91.4%) cases. Mean examination time was 3.5 min. In Group 1, occult sphincter defect was suspected in 10/127 women (7.9%). These patients were excluded from measurement calculations, leaving 117 cases for analysis. The internal sphincter was consistently visualized in all the remaining patients (n = 117), while the external sphincter was fully visualized in 99/117 women (84.6%), and partially visualized in the remainder. Mean internal sphincter thickness was 2.60, 2.55, 2.60 and 2.72 mm at the 12, 3, 6 and 9 o'clock positions, respectively, and mean internal sphincter length was 3.34 cm. Mean external sphincter thickness was 4.15, 4.20, 4.21 and 4.20 mm at the 12, 3, 6 and 9 o'clock measurement points. In Group 2, 3DTUS confirmed anatomic abnormalities in all the women in the area surrounding the 12 o'clock position. Evaluation of sphincter tears and their position and length was possible using the longitudinal view. Thinning of the internal sphincter in the area of damage and thickening on the opposite side, the 'half moon sign', sphincter discontinuity, thickening of the external sphincter in the area of repair and abnormality of mucous folds, seemed to be common signs of third-degree intrapartum sphincter tears, even after repair. CONCLUSIONS: 3DTUS is an accessible and promising method for postpartum sphincter evaluation, that is apparently well tolerated by patients. Reference data for sphincter anatomy representative of findings at transperineal ultrasound in primiparous women in the postpartum period have been established.

Rendering in fetal cardiac scanning: the intracardiac septa and the coronal atrioventricular valve planes.

OBJECTIVE: In this study we aimed to apply spatio-temporal image correlation (STIC) rendering to visualize the virtual planes of the interventricular and interatrial septa (IVS, IAS) as well as the atrioventricular (AV) annuli plane just distal to the semilunar valves (coronal atrioventricular (CAV) plane) in normal and pathological fetal hearts, to ascertain whether these planes add to fetal cardiac examination. METHODS: Unselected gravidae presenting for anatomy scan or patients referred for fetal echocardiography in the second and third trimesters of pregnancy with suspected or diagnosed cardiac malformation were scanned using the five planes technique with the STIC modality to obtain cardiac volume sets for each patient. Rendering capabilities were employed to obtain the 'virtual planes' to evaluate the IVS, IAS, AV annuli, and size and alignment of the great vessels. RESULTS: A total of 136 normal scans were performed to establish a learning curve for STIC acquisition and post-processing rendering and analysis. An additional 35 cases with cardiac anomalies were accrued. In 131/136 (96.3%) normal scans the IAS and IVS were visualized successfully, while in 127/136 (93.4%) normal fetuses the CAV plane was successfully visualized. In 13 anomalous cases the IVS plane improved ventricular septal defect (VSD) evaluation, and in four the IAS plane contributed to foramen ovale evaluation. The modality improved visualization of the septa and the assessment of the defects, as well as the foramen ovale flap and pattern of movement of the foramen ovale. In five cases the CAV plane improved evaluation of the alignment of the major vessels in relation to the AV annuli, and in three the evaluation of the semilunar valves, with or without malalignment of the great vessels. CONCLUSIONS: Rendering STIC technology allows the visualization of virtual planes (IAS, IVS, AV annuli-CAV plane), which can clarify our understanding of anatomical defects and may improve communication with the management team and family.

Paula method of circular muscle exercises for urinary stress incontinence--a clinical trial.

The aim of this study was to determine the efficacy of the Paula method of circular muscle training in the management of stress incontinence (SI). The theory behind this method states that activity of distant sphincters affects other muscles. In a pilot study, 59 women, mainly hospital employees, were randomly assigned to participate in exercises according to the Paula method or pelvic floor training. Efficacy was measured by reports of incontinence, quality of life (I-QOL), pad test, and pelvic floor muscle strength (assessed by perineometer and digital examination). Both the Paula exercises and pelvic floor training produced significant changes in urinary leakage compared to baseline as measured by the pad test [mean decrease of 5.4 g (p=0.002) and 9.5 g (p=0.003), respectively]. Women randomized to the Paula method reported improvement in I-QOL scores. The Paula method was found to be efficacious for SI in a population of Israeli women. Larger community-based studies will be required to confirm these results and enable evaluation of between-group differences.

Adverse outcome of isolated fetal intra-abdominal umbilical vein varix despite close monitoring.

BACKGROUND AND OBJECTIVES: Fetal intra-abdominal umbilical vein (FIUV) varix-a focal dilatation of the umbilical vein-is an uncommon entity. Outcome varies from spontaneous resolution to fetal death. We describe here the experience of our center with this perplexing entity. METHODS: Case series review of seven cases of isolated FIUV treated in a tertiary care center from 2000 to 2003. RESULTS: We describe seven cases of isolated FIUV varix with varying natural history, follow-up strategies, and fetal outcome. In one of the cases, intrauterine fetal demise occurred despite close follow-up. CONCLUSIONS: We suggest that the course of FIUV is unpredictable, with a high fetal mortality rate. Close fetal monitoring with early delivery at 34 weeks' gestation should be advocated.

Eph and ephrin expression in normal placental development and preeclampsia.

Eph receptors and their ephrin ligands play a fundamental role in embryogenesis. Their functions include cell targeting and angiogenesis. In placental development, trophoblasts migrate and invade maternal tissue and spiral arteries, where they play a role in both anchoring the placenta to the uterus and increasing blood flow to the developing fetus (interstitial and endovascular invasions). We investigated the cellular distribution and expression patterns of representative Eph and ephrin RNA and protein in an effort to identify the molecules involved in trophoblast migration during normal placental development and placental pathologies. We found ephrin-A1 expressed exclusively in the invasive extravillous trophoblast (EVT) cell lineage. We therefore proceeded to investigate ephrin-A1 in placental pathologies with defects in EVT invasion. In preeclampsia, where trophoblast invasion is shallow, we observed ephrin-A1 expression similar to normal placenta. Furthermore, in initial experiments on the deeply invading trophoblasts of placenta accreta, which lacks decidua, ephrin-A1 is found to be expressed highly in extravillous trophoblasts that have invaded the myometrium. In addition, we found the prototype ephrin-A1 receptor, EphA2, localized in several placental cell types. EphB4 and ephrin-B2 molecules, which have specific expression patterns during artery and vein development, respectively, were also expressed in the placenta. The cell specific distribution of ephrin-A1 suggests that it may play a role in targeting and migration of trophoblasts, and in the vascular remodeling induced by the invading extravillous trophoblasts. Failure of ephrin-A1 expression is unlikely to be the primary cause in defective migration of trophoblasts observed in preeclampsia. Specific roles for other Eph and ephrin proteins remain to be investigated.

Gender gap in coronary artery disease: comparison of the extent, severity and risk factors in men and women aged 45-65 years.

This retrospective study aimed to characterize coronary artery disease (CAD) and its risk factors among relatively young women, as compared to men in a similar age group. Confirmed cases of CAD were compared regarding their medical background, performance and outcome of coronary artery procedures, physical profile and lifestyle information. The study population included 179 women and 270 men aged 45-65 years who were hospitalized during the study period 1990-1995 in the Hadassah Medical Centers. Significantly more women presented with histories of prior myocardial infarction and a higher number of vessels occluded by 80% or more and required percutaneous transluminal coronary angioplasty for 3 or more arteries, and the women had a higher incidence of risk factors such as diabetes, hypertension and hypercholesterolemia than their male counterparts.

A study of human leukocyte antigen G expression in hydatidiform moles.

OBJECTIVE: Human leukocyte antigen G (HLA-G) is a nonclassic major histocompatibility gene normally expressed only in extravillous trophoblasts throughout pregnancy. It may be responsible in part for the successful evasion of the hemiallogenic trophoblasts from maternal immune surveillance. We investigated whether HLA-G is expressed in molar pregnancies. STUDY DESIGN: We examined 5 complete hydatidiform mole specimens and 5 partial hydatidiform mole specimens to determine whether HLA-G is expressed by immunohistochemistry and by RNA in situ hybridization analysis. RESULTS: We found that both the protein and RNA of HLA-G is expressed in complete and partial hydatidiform moles. CONCLUSION: HLA-G RNA and protein are expressed in molar pregnancies. HLA-G expression is independent of embryonic development and may therefore be an integral part of placental development. Furthermore, expression of HLA-G in the complete hydatidiform mole, a naturally occurring androgenote, confirms expression of the paternal allele of HLA-G. Imprinting of HLA-G is therefore unlikely to play a role in protecting fetal trophoblasts from maternal immune rejection.

Antenatal presentation of carnitine palmitoyltransferase II deficiency.

Carnitine palmitoyl transferase (CPT) II deficiency is usually manifested around puberty by exercise induced myoglobinuria. Two Ashkenazi Jewish sibs with the rare antenatal form of CPTII deficiency are reported. On the 5th gestational month periventricular calcifications and markedly enlarged kidneys were found in both of them. The activity of CPTII in lymphocytes was undetectable and both sibs were homozygous for the 1237delAG mutation. Because of the serious consequences of homozygosity for this mutation, genotype determination of all Ashkenazi patients with the adolescent form of CPTII deficiency is warranted.

Gynecological aspects of female familial dysautonomia.

BACKGROUND: Familial dysautonomia is a genetic disease in which there is a defect in the autonomic and sensory nervous systems. These systems have a major role in the reproductive system. OBJECTIVE: To study the inter-relationship of autonomic and sensory dysfunction and gynecological function. METHODS: The gynecological histories of 48 women with familial dysautonomia were analyzed retrospectively. Their mean age was 22.25 years (range 12-47). Thirty-three women (65%) were available for further questioning and investigation of hormonal status. RESULTS: Menarche had occurred in 32 of the 48 (66.7%). Their average age of menarche was significantly delayed as compared to their unaffected mothers (15.5 vs. 13.6 years respectively, P = 0.002). The most prominent finding was the very high prevalence, 81.2%, of premenstrual symptoms. Seven of 26 had premenstrual syndrome symptoms of dysautonomic crisis. Blood sex hormone levels were normal in 27 of the 33 patients studied. None reached natural menopause. One patient had adenomyosis, and another, dysgerminoma. Three patients became pregnant and delivered healthy infants. CONCLUSION: Menarche is delayed in women with FD, and the physiological monthly hormonal fluctuations may disturb autonomic homeostasis sufficiently to precipitate dysautonomic crisis.