What are the main types of tremors associated with Multiple Sclerosis. How does MS cause tremors in patients. Which medications and non-medicinal treatments are effective for managing MS tremors. How can patients cope with the psychological impact of MS-related tremors.

The Nature of Multiple Sclerosis Tremors

Multiple Sclerosis (MS) is a complex neurological condition that can manifest in various symptoms, including tremors. These involuntary movements can significantly impact a person’s daily life and overall quality of living. Understanding the nature of MS tremors is crucial for both patients and healthcare providers to develop effective management strategies.

Tremors in MS are uncontrollable shaking or quivering movements that can affect different parts of the body, such as the head, arms, or legs. They occur due to damage to the myelin sheath, the protective covering of nerves in the brain and spinal cord. This damage disrupts the normal communication between the brain and muscles, leading to tremors.

How prevalent are tremors in MS patients?

Tremors are a common symptom in MS, affecting a significant portion of patients. Studies suggest that up to 60% of people with MS experience some form of tremor during the course of their disease. The severity and impact of these tremors can vary greatly from person to person, ranging from mild inconveniences to severe disabilities that interfere with daily activities.

Types of Tremors Associated with Multiple Sclerosis

MS can cause several types of tremors, each with distinct characteristics and impacts on a patient’s life. Understanding these different types is essential for accurate diagnosis and tailored treatment approaches.

• Intention Tremor: The most common type in MS patients
• Postural Tremor: Occurs when maintaining a position against gravity
• Resting Tremor: Less common in MS, more associated with Parkinson’s disease
• Nystagmus: Involves involuntary eye movements

Intention Tremor: The Primary Culprit in MS

Intention tremor is the most prevalent and often the most problematic type of tremor experienced by MS patients. It is characterized by shaking that begins or worsens when a person attempts to perform a purposeful movement, such as reaching for an object or touching a specific point. This type of tremor can significantly impact daily activities like eating, writing, or dressing.

The severity of intention tremor often increases as the intended target is approached, making precise movements challenging. For many MS patients, this can lead to frustration and a decreased sense of independence in performing simple tasks.

Postural Tremor: Challenges in Maintaining Position

Postural tremors occur when a person maintains a position against gravity, such as holding their arms outstretched or standing upright. These tremors are absent when the affected body part is at rest or supported. For MS patients, postural tremors can make activities like holding a cup, reading a book, or maintaining balance while standing particularly difficult.

Resting Tremor: Less Common but Still Present

While resting tremors are more commonly associated with Parkinson’s disease, they can also occur in some MS patients. These tremors are present when the body is at rest and tend to decrease or disappear during voluntary movement. Although less frequent in MS, resting tremors can still contribute to the overall burden of the disease for some individuals.

Nystagmus: When Tremors Affect the Eyes

Nystagmus is a specific type of tremor that affects the eyes, causing involuntary, rhythmic eye movements. In MS patients, nystagmus can result in visual disturbances, such as difficulty focusing or a sensation that the environment is moving. This can lead to issues with balance, reading, and overall visual perception.

The Neurological Basis of MS Tremors

To fully grasp the nature of MS tremors, it’s important to understand their neurological basis. Multiple Sclerosis is an autoimmune condition that attacks the myelin sheath, a protective covering around nerve fibers in the central nervous system. This damage, known as demyelination, disrupts the normal transmission of electrical signals along nerve pathways.

In the case of tremors, the primary area of concern is the cerebellum, a region of the brain responsible for coordinating movement, balance, and fine motor control. When MS lesions occur in or near the cerebellum or its connecting pathways, it can lead to the development of tremors.

How does cerebellar damage lead to tremors?

The cerebellum plays a crucial role in smoothing out and coordinating complex movements. It receives input from various parts of the brain and body about the intended movement and current body position. It then processes this information and sends corrective signals to ensure smooth, accurate movements.

When MS damages the cerebellum or its connections, this fine-tuning process is disrupted. As a result, the brain may overcompensate or undercompensate for movements, leading to the characteristic shaking or trembling associated with MS tremors. This is particularly evident in intention tremors, where the cerebellum’s role in guiding precise movements is compromised.

Diagnosis and Assessment of MS Tremors

Accurate diagnosis and assessment of MS tremors are crucial for developing effective treatment plans. Neurologists and MS specialists employ various tools and techniques to evaluate the type, severity, and impact of tremors on a patient’s life.

What methods are used to diagnose and assess MS tremors?

Diagnosing and assessing MS tremors typically involves a combination of clinical observation, patient history, and specialized tests. Some common methods include:

1. Neurological Examination: A thorough physical exam to observe tremors and assess their characteristics.
2. Tremor Rating Scales: Standardized scales to quantify tremor severity and impact on daily activities.
3. Electromyography (EMG): Measures muscle activity and can help distinguish between different types of tremors.
4. Accelerometry: Uses sensors to measure the frequency and amplitude of tremors objectively.
5. Functional Tests: Assesses the impact of tremors on specific tasks like writing or pouring water.
6. Imaging Studies: MRI scans to identify MS lesions that may be contributing to tremors.

These assessments not only help in diagnosis but also provide valuable information for tailoring treatment approaches and monitoring progress over time.

Pharmacological Treatments for MS Tremors

Managing tremors in MS patients often involves a multifaceted approach, with pharmacological interventions playing a significant role. While there are currently no medications specifically approved for treating MS tremors, several drugs have shown efficacy in managing these symptoms.

Which medications are commonly used to treat MS tremors?

Several classes of medications have been found to be helpful in managing MS tremors, although their effectiveness can vary from patient to patient. Some commonly prescribed medications include:

• Anticonvulsants: Drugs like primidone (Mysoline) and gabapentin (Neurontin) may help reduce tremor severity.
• Beta-blockers: Propranolol (Inderal) has shown effectiveness in some cases of MS tremors.
• Benzodiazepines: Clonazepam (Klonopin) can help reduce tremors, particularly in cases with associated anxiety.
• Carbonic anhydrase inhibitors: Acetazolamide (Diamox) may be beneficial for some patients.
• Isoniazid: Originally an anti-tuberculosis drug, it has shown some promise in treating cerebellar tremors.
• Cannabinoids: Some studies suggest that medical cannabis may help alleviate tremors in some MS patients.

It’s important to note that the efficacy of these medications can vary significantly between individuals. Healthcare providers often need to try different drugs or combinations to find the most effective treatment for each patient.

Are there potential side effects of tremor medications?

As with any medication, drugs used to treat MS tremors can have side effects. These may include drowsiness, dizziness, fatigue, and in some cases, cognitive impairment. The potential benefits of tremor reduction must be carefully weighed against these possible side effects. Close monitoring and regular follow-ups with healthcare providers are essential to ensure the optimal balance between symptom control and quality of life.

Non-Pharmacological Interventions for MS Tremors

While medications play a crucial role in managing MS tremors, non-pharmacological interventions are equally important. These approaches can significantly improve a patient’s ability to manage tremors and enhance overall quality of life.

What are effective non-medicinal treatments for MS tremors?

Several non-pharmacological interventions have shown promise in managing MS tremors:

1. Physical Therapy: Customized exercise programs can improve strength, coordination, and balance, potentially reducing tremor severity.
2. Occupational Therapy: Teaches adaptive techniques and introduces assistive devices to help manage daily tasks affected by tremors.
3. Speech Therapy: For patients with tremors affecting speech, specialized exercises can improve clarity and control.
4. Adaptive Devices: Weighted utensils, wrist weights, or specially designed writing instruments can help stabilize tremors during specific activities.
5. Braces and Splints: Can provide support and limit the range of motion in affected limbs, reducing tremor impact.
6. Cooling Therapy: Some patients find that cooling the affected body part can temporarily reduce tremor severity.
7. Stress Management Techniques: Since stress can exacerbate tremors, relaxation techniques like meditation or deep breathing exercises can be beneficial.
8. Deep Brain Stimulation (DBS): In severe cases, this surgical intervention may be considered, although it’s typically reserved for patients with intractable tremors.

These non-pharmacological approaches are often used in combination with medications to provide comprehensive tremor management. The effectiveness of each method can vary between individuals, so a personalized approach is crucial.

Psychological Impact and Coping Strategies for MS Tremors

The impact of MS tremors extends beyond physical symptoms, often affecting a patient’s psychological well-being and social interactions. Understanding and addressing these psychological aspects is crucial for comprehensive care and improved quality of life.

How do MS tremors affect a patient’s mental health?

MS tremors can have significant psychological effects on patients, including:

• Anxiety and Depression: The unpredictable nature of tremors and their impact on daily activities can lead to feelings of anxiety and depression.
• Social Isolation: Embarrassment or difficulty in social situations due to visible tremors may cause some patients to withdraw from social activities.
• Loss of Independence: As tremors impact the ability to perform routine tasks, patients may experience a diminished sense of independence and self-esteem.
• Frustration and Anger: The challenges posed by tremors in everyday life can lead to feelings of frustration and anger.
• Fear of Disease Progression: Tremors may be seen as a visible sign of disease progression, causing worry about the future.

What coping strategies can help MS patients manage the psychological impact of tremors?

Several strategies can help patients cope with the psychological challenges associated with MS tremors:

1. Cognitive Behavioral Therapy (CBT): Can help patients develop positive coping mechanisms and manage anxiety or depression related to their symptoms.
2. Support Groups: Connecting with others who have similar experiences can provide emotional support and practical advice.
3. Mindfulness and Relaxation Techniques: Practices like meditation or progressive muscle relaxation can help manage stress and improve overall well-being.
4. Education and Self-Advocacy: Understanding MS and its symptoms can empower patients to better manage their condition and communicate effectively with healthcare providers.
5. Adaptive Strategies: Learning new ways to perform tasks affected by tremors can help maintain independence and boost confidence.
6. Open Communication: Encouraging open discussions about tremors with family, friends, and colleagues can foster understanding and support.
7. Setting Realistic Goals: Breaking tasks into manageable steps and celebrating small victories can help maintain a positive outlook.

By addressing both the physical and psychological aspects of MS tremors, patients can develop a more holistic approach to managing their symptoms and maintaining a good quality of life.

Emerging Research and Future Directions in MS Tremor Management

The field of MS tremor research is dynamic, with ongoing studies exploring new treatment options and refining our understanding of tremor mechanisms. Staying informed about these developments can provide hope and new management strategies for patients and healthcare providers alike.

What are some promising areas of research in MS tremor treatment?

Several exciting areas of research hold promise for improved MS tremor management:

• Targeted Neuromodulation: Advanced techniques like transcranial magnetic stimulation (TMS) or focused ultrasound are being investigated for their potential to alleviate tremors non-invasively.
• Novel Pharmacological Approaches: Research into new drug targets and delivery methods may lead to more effective and better-tolerated medications for MS tremors.
• Personalized Medicine: Advances in genetic and biomarker research may allow for more tailored treatment approaches based on individual patient characteristics.
• Rehabilitation Technologies: Virtual reality and robotic-assisted therapy are being explored as tools to enhance traditional rehabilitation methods for tremor management.
• Neuroprotective Strategies: Research into treatments that can slow or prevent the progression of cerebellar damage may have implications for tremor prevention and management.
• Advanced Imaging Techniques: Improved neuroimaging methods may lead to better understanding of tremor mechanisms and guide more precise treatments.

These research directions offer hope for more effective and personalized approaches to managing MS tremors in the future. As our understanding of MS and its associated symptoms continues to grow, so too will our ability to provide comprehensive care and improve the lives of those affected by this challenging condition.

MS Tremors (Postural, Intention, Nystagmus) Causes & Treatment

Written by WebMD Editorial Contributors

• What Is a Tremor?
• What Are the Types of Tremors?
• Why Does MS Cause Tremors?
• Medicines That Treat MS Tremors
• Nonmedicinal Tremor Treatments
• Tremors and Depression
• More

A tremor is when a body part moves or shakes and you can’t control it. Many people with multiple sclerosis (MS) have some form of tremor they can’t control, in different parts of their bodies, like their head, arms, or legs.

• Intention tremor. There’s no shaking when you’re at rest. It starts when you try to reach or grasp something or move your hand or foot to a precise spot. This is the most common form of MS tremor, and it usually causes the most problems in day-to-day life.
• Postural tremors. You shake when you sit or stand, but not when you lie down.
• Resting tremor. You move more when you’re sitting still and less when you move. This is more common with Parkinson’s disease than MS.
• Nystagmus. This type causes jumpy eye movements.

This disease damages the protective sheath (myelin) that covers the nerves in your brain and spinal cord. Tremors result from damage to a part of your brain called the cerebellum. It controls your balance and coordination and smooths out the actions that you make when you move your limbs and eyes or speak.

These problems are one of the hardest MS symptoms to treat. There aren’t any drugs made just to treat MS tremors. Your doctors may prescribe drugs for another condition that could help, like:

• Acetazolamide (Diamox), which treats a type of glaucoma and altitude sickness
• Buspirone (Buspar) and clonazepam (Klonopin), which are anti-anxiety drugs
• Hydroxyzine (Atarax, Vistaril), an antihistamine
• Isoniazid (INH), a drug for tuberculosis
• Primidone (Mysoline), a seizure medicine
• Propranolol (Inderal), which treats heart problems, high blood pressure, and migraines

• Braces: These can hold your joint still and stop extra movement. A brace on your ankle or foot can make it easier to walk. They can help control your arm, hand, or neck, too.
• Deep brain stimulation: This experimental approach is mostly used for people who have tremors from Parkinson’s disease. A doctor implants electrodes into your brain. Wires connect them to a gadget in your chest. You use it to send your brain signals that stop the tremors.
• Medical cannabis: There’s little evidence that cannabis can help with tremors, but study results are mixed and usually only include small numbers of people.
• Physical therapy: It can show you exercises that increase your range of motion, improve your posture and balance, and make your body more stable
• Speech therapy: If you have tremors in your lips, tongue, or jaw, a health professional can work with you to slow your speech, make it clearer, and control the volume.
• Occupational therapist: This person will set you up with special tools called adaptive or assistive devices. They can help you grab things from up high or off the floor, pull up a zipper, or hold a fork more easily.
• Weights: Adding extra weight to a body part can help keep it still. You can also add weights to commonly used items like forks, pencils, pens, eating utensils, canes, and walkers.

Tremors can be tough to handle in social situations. You may feel like you want to be alone, but that can make you feel lonely and depressed. A psychologist or counselor can help you find ways to feel more comfortable in public and keep the tremors from changing how you live your life.

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MS Tremors (Postural, Intention, Nystagmus) Causes & Treatment

Written by WebMD Editorial Contributors

• What Is a Tremor?
• What Are the Types of Tremors?
• Why Does MS Cause Tremors?
• Medicines That Treat MS Tremors
• Nonmedicinal Tremor Treatments
• Tremors and Depression
• More

A tremor is when a body part moves or shakes and you can’t control it. Many people with multiple sclerosis (MS) have some form of tremor they can’t control, in different parts of their bodies, like their head, arms, or legs.

• Intention tremor. There’s no shaking when you’re at rest. It starts when you try to reach or grasp something or move your hand or foot to a precise spot. This is the most common form of MS tremor, and it usually causes the most problems in day-to-day life.
• Postural tremors. You shake when you sit or stand, but not when you lie down.
• Resting tremor. You move more when you’re sitting still and less when you move. This is more common with Parkinson’s disease than MS.
• Nystagmus. This type causes jumpy eye movements.

This disease damages the protective sheath (myelin) that covers the nerves in your brain and spinal cord. Tremors result from damage to a part of your brain called the cerebellum. It controls your balance and coordination and smooths out the actions that you make when you move your limbs and eyes or speak.

These problems are one of the hardest MS symptoms to treat. There aren’t any drugs made just to treat MS tremors. Your doctors may prescribe drugs for another condition that could help, like:

• Acetazolamide (Diamox), which treats a type of glaucoma and altitude sickness
• Buspirone (Buspar) and clonazepam (Klonopin), which are anti-anxiety drugs
• Hydroxyzine (Atarax, Vistaril), an antihistamine
• Isoniazid (INH), a drug for tuberculosis
• Primidone (Mysoline), a seizure medicine
• Propranolol (Inderal), which treats heart problems, high blood pressure, and migraines

• Braces: These can hold your joint still and stop extra movement. A brace on your ankle or foot can make it easier to walk. They can help control your arm, hand, or neck, too.
• Deep brain stimulation: This experimental approach is mostly used for people who have tremors from Parkinson’s disease. A doctor implants electrodes into your brain. Wires connect them to a gadget in your chest. You use it to send your brain signals that stop the tremors.
• Medical cannabis: There’s little evidence that cannabis can help with tremors, but study results are mixed and usually only include small numbers of people.
• Physical therapy: It can show you exercises that increase your range of motion, improve your posture and balance, and make your body more stable
• Speech therapy: If you have tremors in your lips, tongue, or jaw, a health professional can work with you to slow your speech, make it clearer, and control the volume.
• Occupational therapist: This person will set you up with special tools called adaptive or assistive devices. They can help you grab things from up high or off the floor, pull up a zipper, or hold a fork more easily.
• Weights: Adding extra weight to a body part can help keep it still. You can also add weights to commonly used items like forks, pencils, pens, eating utensils, canes, and walkers.

Tremors can be tough to handle in social situations. You may feel like you want to be alone, but that can make you feel lonely and depressed. A psychologist or counselor can help you find ways to feel more comfortable in public and keep the tremors from changing how you live your life.

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Metabolic syndrome. What is Metabolic Syndrome?

IMPORTANT
The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

Metabolic syndrome is a symptom complex, manifested by a violation of the metabolism of fats and carbohydrates, an increase in blood pressure. Patients develop arterial hypertension, obesity, insulin resistance and ischemia of the heart muscle. Diagnosis includes an examination by an endocrinologist, determination of body mass index and waist circumference, assessment of the lipid spectrum, blood glucose. If necessary, an ultrasound examination of the heart and a daily measurement of blood pressure are performed. Treatment consists of lifestyle changes: active sports, a special diet, normalization of weight and hormonal status.

• Causes of metabolic syndrome
• Metabolic syndrome symptoms
• Complications
• Diagnostics
• Treatment of metabolic syndrome
• Prognosis and prevention
• Prices for treatment

General

Metabolic syndrome (syndrome X) is a comorbid disease that includes several pathologies at once: diabetes mellitus, arterial hypertension, obesity, coronary heart disease. The term “syndrome X” was first introduced at the end of the twentieth century by the American scientist Gerald Riven. The prevalence of the disease ranges from 20 to 40%. The disease most often affects people aged 35 to 65 years, male patients are predominantly affected. In women, the risk of developing the syndrome after menopause increases by 5 times. Over the past 25 years, the number of children with this disorder has increased to 7% and continues to increase.

metabolic syndrome

Causes of metabolic syndrome

Syndrome X is a pathological condition that develops under the simultaneous influence of several factors. The main reason is a violation of the sensitivity of cells to insulin. Insulin resistance is based on genetic predisposition, diseases of the pancreas. Other factors contributing to the occurrence of a symptom complex include:

• Malnutrition. Increased consumption of carbohydrates and fats, as well as overeating, lead to weight gain. If the number of calories consumed exceeds energy expenditure, body fat accumulates.
• Adynamia. An inactive lifestyle, “sedentary” work, lack of sports load contribute to a slowdown in metabolism, obesity and the appearance of insulin resistance.
• Hypertension. Long-term uncontrolled episodes of hypertension cause circulatory disorders in arterioles and capillaries, vasospasm occurs, and tissue metabolism is disturbed.
• Nervous tension. Stress, intense experiences lead to endocrine disorders and overeating.
• Hormonal imbalance in women. During menopause, testosterone levels increase and estrogen production decreases. This causes a slowdown in the metabolism in the body and an increase in body fat according to the android type.
• Hormonal imbalance in men. A decrease in testosterone levels after 45 contributes to weight gain, impaired insulin metabolism, and increased blood pressure.

Metabolic syndrome symptoms

The first signs of metabolic disorders are fatigue, apathy, unmotivated aggression and a bad mood when hungry. Usually patients are selective in their choice of food, they prefer “fast” carbohydrates (cakes, bread, sweets). Consumption of sweets causes short-term mood swings. Further development of the disease and atherosclerotic changes in the vessels lead to periodic pain in the heart, heart attacks. High insulin levels and obesity provoke disorders of the digestive system, the appearance of constipation. The function of the parasympathetic and sympathetic nervous system is disturbed, tachycardia, tremor of the extremities develop.

The disease is characterized by an increase in the fat layer not only in the chest, abdomen, upper limbs, but also around the internal organs (visceral fat). A sharp weight gain contributes to the appearance of burgundy striae (stretch marks) on the skin of the abdomen and thighs. There are frequent episodes of increased blood pressure above 139/89 mm Hg. Art., accompanied by nausea, headache, dry mouth and dizziness. There is hyperemia of the upper half of the body, due to a violation of the tone of peripheral vessels, increased sweating due to malfunctions in the autonomic nervous system.

Complications

Metabolic syndrome leads to hypertension, atherosclerosis of the coronary arteries and cerebral vessels and, as a result, heart attack and stroke. The state of insulin resistance causes the development of type 2 diabetes mellitus and its complications – retinopathy and diabetic nephropathy. In men, the symptom complex contributes to a weakening of potency and impaired erectile function. In women, syndrome X is the cause of polycystic ovaries, endometriosis, and decreased libido. In reproductive age, menstrual irregularities and infertility may develop.

Diagnostics

Metabolic syndrome has no obvious clinical symptoms; the pathology is often diagnosed at a late stage after the onset of complications. Diagnostics includes:

• Specialist inspection. An endocrinologist examines the history of life and disease (heredity, daily routine, diet, concomitant diseases, living conditions), conducts a general examination (BP parameters, weighing). If necessary, the patient is referred for a consultation with a nutritionist, cardiologist, gynecologist or andrologist.
• Determination of anthropometric indicators. The android type of obesity is diagnosed by measuring waist circumference. With syndrome X, this indicator in men is more than 102 cm, in women – 88 cm. Excess weight is detected by calculating the body mass index (BMI) using the formula BMI = weight (kg) / height (m)². Obesity is diagnosed with a BMI greater than 30.
• Laboratory tests. Lipid metabolism is disturbed: the level of cholesterol, LDL, triglycerides rises, the level of HDL decreases. Disorder of carbohydrate metabolism leads to an increase in glucose and insulin in the blood.
• Additional research. According to the indications, daily monitoring of blood pressure, ECG, ECHO-KG, ultrasound of the liver and kidneys, glycemic profile and glucose tolerance test are prescribed.

Metabolic disorders should be differentiated from the disease and Itsenko-Cushing’s syndrome. If difficulties arise, the determination of the daily excretion of cortisol in the urine, the dexamethasone test, the tomography of the adrenal glands or the pituitary gland are performed. Differential diagnosis of a metabolic disorder is also performed with autoimmune thyroiditis, hypothyroidism, pheochromocytoma, and stromal ovarian hyperplasia syndrome. In this case, the level of ACTH, prolactin, FSH, LH, thyroid-stimulating hormone is additionally determined.

Treatment of metabolic syndrome

Treatment of syndrome X involves complex therapy aimed at normalizing weight, blood pressure parameters, laboratory parameters and hormonal levels.

• Power mode. Patients need to exclude easily digestible carbohydrates (pastries, sweets, sugary drinks), fast food, canned foods, limit the amount of salt and pasta consumed. The daily diet should include fresh vegetables, seasonal fruits, cereals, lean fish and meat. Food should be consumed 5-6 times a day in small portions, chewing thoroughly and not drinking water. From drinks it is better to choose unsweetened green or white tea, fruit drinks and compotes without added sugar.
• Physical activity. In the absence of contraindications from the musculoskeletal system, jogging, swimming, Nordic walking, Pilates and aerobics are recommended. Physical activity should be regular, at least 2-3 times a week. Useful morning exercises, daily walks in the park or forest belt.
• Medical therapy. Medications are prescribed to treat obesity, reduce pressure, normalize the metabolism of fats and carbohydrates. In violation of glucose tolerance, metformin preparations are used. Correction of dyslipidemia with the ineffectiveness of dietary nutrition is carried out with statins. For hypertension, ACE inhibitors, calcium channel blockers, diuretics, beta-blockers are used. To normalize weight, drugs are prescribed that reduce the absorption of fats in the intestines.

Prognosis and prevention

With timely diagnosis and treatment of the metabolic syndrome, the prognosis is favorable. Late detection of pathology and the lack of complex therapy cause serious complications in the kidneys and cardiovascular system. Prevention of the syndrome includes a balanced diet, giving up bad habits, and regular exercise. It is necessary to control not only weight, but also the parameters of the figure (waist circumference). In the presence of concomitant endocrine diseases (hypothyroidism, diabetes mellitus), dispensary observation of an endocrinologist and a study of the hormonal background are recommended.

Sources

1. treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

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