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| Acromegaly |
Acromegaly is a hormonal disorder that results when the pituitary gland
produces excess growth hormone (GH). It most commonly affects
middle-aged adults and can result in serious illness and premature death.
The name acromegaly comes from the Greek words for "extremities" and
"enlargement" and reflects one of its most common symptoms, the
abnormal growth of the hands and feet.
Overgrowth of bone and cartilage often leads to arthritis. When tissue
thickens, it may trap nerves, causing carpal tunnel syndrome,
characterized by numbness and weakness of the hands. Other symptoms
of acromegaly include thick, coarse, oily skin; skin tags; enlarged lips,
nose and tongue; deepening of the voice due to enlarged sinuses and
vocal cords; snoring due to upper airway obstruction; excessive sweating
and skin odor; fatigue and weakness; headaches; impaired vision;
abnormalities of the menstrual cycle and sometimes breast discharge in
women; and impotence in men. There may be enlargement of body
organs, including the liver, spleen, kidneys and heart.
The most serious health consequences of acromegaly are diabetes
mellitus, hypertension, and increased risk of cardiovascular disease.
Patients with acromegaly are also at increased risk for polyps of the colon
that can develop into cancer.
When growth hormone-producing tumors occur in childhood, the disease
that results is called gigantism rather than acromegaly. Fusion of the
growth plates of the long bones occurs after puberty so that
development of excessive growth hormone production in adults does not
result in increased height. Prolonged exposure to excess growth
hormone before fusion of the growth plates causes increased growth of
the long bones and increased height.
What causes acromegaly?
Acromegaly is caused by prolonged overproduction of growth hormone
by the pituitary gland. The pituitary is a small gland at the base of the
brain that produces several important hormones to control body
functions such as growth and development, reproduction, and
metabolism. Growth hormone is part of a cascade of hormones that, as
the name implies, regulates the physical growth of the body. This
cascade begins in a part of the brain called the hypothalamus, which
makes hormones that regulate the pituitary. One of these, growth
hormone-releasing hormone (GHRH), stimulates the pituitary gland to
produce growth hormone. Another hypothalamic hormone, somatostatin,
inhibits growth hormone production and release. Secretion of growth
hormone by the pituitary into the bloodstream causes the production of
another hormone, called insulin-like growth factor 1 (IGF-1), in the liver.
IGF-1 is the factor that actually causes the growth of bones and other
tissues of the body. IGF-1, in turn, signals the pituitary to reduce GH
production. GHRH, somatostatin, GH, and IGF-1 levels in the body are
tightly regulated by each other and by sleep, exercise, stress, food intake
and blood sugar levels. If the pituitary continues to make growth
hormone independent of the normal regulatory mechanisms, the level of
IGF-1 continues to rise, leading to bone growth and organ enlargement.
The excess GH also causes changes in sugar and lipid metabolism and
can cause diabetes.
Pituitary Tumors
In over 90 percent of acromegaly patients, the overproduction of growth
hormone is caused by a benign tumor of the pituitary gland, called an
adenoma. These tumors produce excess growth hormone and, as they
expand, compress surrounding brain tissues, such as the optic nerves.
This expansion causes the headaches and visual disturbances that are
often symptoms of acromegaly. In addition, compression of the
surrounding normal pituitary tissue can alter production of other
hormones, leading to changes in menstruation and breast discharge in
women and impotence in men.
There is a marked variation in rates of growth hormone production and
the aggressiveness of the tumor. Some adenomas grow slowly and
symptoms of growth hormone excess are often not noticed for many
years. Other adenomas grow rapidly and invade surrounding brain areas
or the sinuses, which are located near the pituitary. In general, younger
patients tend to have more aggressive tumors.
Non-pituitary Tumors
In a few patients, acromegaly is caused not by pituitary tumors but by
tumors of the pancreas, lungs, and adrenal glands. These tumors also
lead to an excess of growth hormone, either because they produce
growth hormone themselves or, more frequently, because they produce
GHRH, the hormone that stimulates the pituitary to make growth
hormone. In these patients, the excess GHRH can be measured in the
blood and establishes that the cause of the acromegaly is not due to a
pituitary defect. When these non-pituitary tumors are surgically removed,
GH levels fall and the symptoms of acromegaly improve.
In patients with GHRH-producing, non-pituitary tumors, the pituitary still
may be enlarged and may be mistaken for a tumor.
How common is acromegaly?
Small pituitary adenomas are common. During autopsies, they are found
in up to 25 percent of the U.S. population. However, these tumors rarely
cause symptoms or produce excessive GH or other pituitary hormones.
Scientists estimate that about 3 out of every million people develop
acromegaly each year and that 40 to 60 out of every million people suffer
from the disease at any time. However, because the clinical diagnosis of
acromegaly often is missed, these numbers probably underestimate the
frequency of the disease.
How is acromegaly diagnosed?
If a doctor suspects acromegaly, he or she can measure the growth
hormone level in the blood after a patient has fasted overnight to
determine if it is elevated. However, a single measurement of an elevated
blood growth hormone level is not enough to diagnose acromegaly,
because growth hormone is secreted by the pituitary in spurts and its
concentration in the blood can vary widely from minute to minute. At a
given moment, a patient with acromegaly may have a normal growth
hormone level, whereas a growth hormone level in a healthy person may
be five times higher.
Because of these problems, more accurate information can be obtained
when growth hormone is measured under conditions in which growth
hormone secretion is normally suppressed. Physicians often use the oral
glucose tolerance test to diagnose acromegaly, because ingestion of 75 g
of the sugar glucose lowers blood growth hormone levels less than 2
ng/ml in healthy people. In patients with growth hormone
overproduction, this reduction does not occur. The glucose tolerance test
is the most reliable method of confirming a diagnosis of acromegaly.
Physicians also can measure IGF-1 levels in patients with suspected
acromegaly. As mentioned earlier, elevated growth hormone levels
increase IGF-1 blood levels. Because IGF-1 levels are much more stable
over the course of the day, they are often a more practical and reliable
measure than GH levels. Elevated IGF-1 levels almost always indicate
acromegaly. However, a pregnant woman's IGF-1 levels are two to three
times higher than normal. In addition, physicians must be aware that
IGF-1 levels decline in aging people and may be abnormally low in patients
with poorly controlled diabetes mellitus.
After acromegaly has been diagnosed by measuring GH or IGF-1, imaging
techniques, such as computed tomography (CT) scans or magnetic
resonance imaging (MRI) scans of the pituitary are used to locate the
tumor that causes the GH overproduction. Both techniques are excellent
tools to visualize a tumor without surgery. If scans fail to detect a
pituitary tumor, the physician should look for non-pituitary tumors in the
chest, abdomen, or pelvis as the cause for excess GH. The presence of
such tumors usually can be diagnosed by measuring GHRH in the blood
and by a CT scan of possible tumor sites.
How is acromegaly treated?
The goals of treatment are to reduce GH production to normal levels, to
relieve the pressure that the growing pituitary tumor exerts on the
surrounding brain areas, to preserve normal pituitary function, and to
reverse or ameliorate the symptoms of acromegaly. Currently, treatment
options include surgical removal of the tumor, drug therapy, and
radiation therapy of the pituitary.
Surgery
Surgery is a rapid and effective treatment. The surgeon reaches the
pituitary through an incision in the nose and, with special tools, removes
the tumor tissue in a procedure called transsphenoidal surgery. This
procedure promptly relieves the pressure on the surrounding brain
regions and leads to a lowering of GH levels. If the surgery is successful,
facial appearance and soft tissue swelling improve within a few days.
Surgery is most successful in patients with blood GH levels below 40
ng/ml before the operation and with pituitary tumors no larger than 10
mm in diameter. Success depends on the skill and experience of the
surgeon. The success rate also depends on what level of GH is defined as
a cure. The best measure of surgical success is normalization of GH and
IGF-1 levels. Ideally, GH should be less than 2 ng/ml after an oral glucose
load. A review of GH levels in 1,360 patients worldwide immediately after
surgery revealed that 60 percent had random GH levels below 5 ng/ml.
Complications of surgery may include cerebrospinal fluid leaks, meningitis,
or damage to the surrounding normal pituitary tissue, requiring lifelong
pituitary hormone replacement.
Even when surgery is successful and hormone levels return to normal,
patients must be carefully monitored for years for possible recurrence.
More commonly, hormone levels may improve, but not return completely
to normal. These patients may then require additional treatment, usually
with medications.
Drug Therapy
Two medications currently are used to treat acromegaly. These drugs
reduce both growth hormone secretion and tumor size. Medical therapy
is sometimes used to shrink large tumors before surgery. Bromocriptine
(Parlodel®) in divided doses of about 20 mg daily reduces GH secretion
from some pituitary tumors. Side effects include gastrointestinal upset,
nausea, vomiting, light-headedness when standing, and nasal
congestion. These side effects can be reduced or eliminated if medication
is started at a very low dose at bedtime, taken with food, and gradually
increased to the full therapeutic dose.
Because bromocriptine can be taken orally, it is an attractive choice as
primary drug or in combination with other treatments. However,
bromocriptine lowers GH and IGF-1 levels and reduces tumor size in less
than half of patients with acromegaly. Some patients report improvement
in their symptoms although their GH and IGF-1 levels still are elevated.
The second medication used to treat acromegaly is octreotide
(Sandostatin®). Octreotide is a synthetic form of a brain hormone,
somatostatin, that stops GH production. This drug must be injected
under the skin every 8 hours for effective treatment. Most patients with
acromegaly respond to this medication. In many patients, GH levels fall
within one hour and headaches improve within minutes after the
injection. Several studies have shown that octreotide is effective for
long-term treatment. Octreotide also has been used successfully to treat
patients with acromegaly caused by non-pituitary tumors.
Because octreotide inhibits gastrointestinal and pancreatic function,
long-term use causes digestive problems such as loose stools, nausea,
and gas in one third of patients. In addition, approximately 25 percent of
patients develop gallstones, which are usually asymptomatic. In rare
cases, octreotide treatment can cause diabetes. On the other hand,
scientists have found that in some acromegaly patients who already have
diabetes, octreotide can reduce the need for insulin and improve blood
sugar control.
Radiation Therapy
Radiation therapy has been used both as a primary treatment and
combined with surgery or drugs. It is usually reserved for patients who
have tumor remaining after surgery. These patients often also receive
medication to lower GH levels. Radiation therapy is given in divided doses
over four to six weeks. This treatment lowers GH levels by about 50
percent over 2 to 5 years. Patients monitored for more than 5 years
show significant further improvement. Radiation therapy causes a gradual
loss of production of other pituitary hormones with time. Loss of vision
and brain injury, which have been reported, are very rare complications of
radiation treatments.
No single treatment is effective for all patients. Treatment should be
individualized depending on patient characteristics, such as age and
tumor size. If the tumor has not yet invaded surrounding brain tissues,
removal of the pituitary adenoma by an experienced neurosurgeon is
usually the first choice. After surgery, a patient must be monitored for a
long time for increasing GH levels. If surgery does not normalize hormone
levels or a relapse occurs, a doctor will usually begin additional drug
therapy. The first choice should be bromocriptine because it is easy to
administer; octreotide is the second alternative. With both medications,
long-term therapy is necessary because their withdrawal can lead to
rising GH levels and tumor re-expansion. Radiation therapy is generally
used for patients whose tumors are not completely removed by surgery;
for patients who are not good candidates for surgery because of other
health problems; and for patients who do not respond adequately to
surgery and medication.
Content Source NIDDK.NIH
produces excess growth hormone (GH). It most commonly affects
middle-aged adults and can result in serious illness and premature death.
The name acromegaly comes from the Greek words for "extremities" and
"enlargement" and reflects one of its most common symptoms, the
abnormal growth of the hands and feet.
Overgrowth of bone and cartilage often leads to arthritis. When tissue
thickens, it may trap nerves, causing carpal tunnel syndrome,
characterized by numbness and weakness of the hands. Other symptoms
of acromegaly include thick, coarse, oily skin; skin tags; enlarged lips,
nose and tongue; deepening of the voice due to enlarged sinuses and
vocal cords; snoring due to upper airway obstruction; excessive sweating
and skin odor; fatigue and weakness; headaches; impaired vision;
abnormalities of the menstrual cycle and sometimes breast discharge in
women; and impotence in men. There may be enlargement of body
organs, including the liver, spleen, kidneys and heart.
The most serious health consequences of acromegaly are diabetes
mellitus, hypertension, and increased risk of cardiovascular disease.
Patients with acromegaly are also at increased risk for polyps of the colon
that can develop into cancer.
When growth hormone-producing tumors occur in childhood, the disease
that results is called gigantism rather than acromegaly. Fusion of the
growth plates of the long bones occurs after puberty so that
development of excessive growth hormone production in adults does not
result in increased height. Prolonged exposure to excess growth
hormone before fusion of the growth plates causes increased growth of
the long bones and increased height.
What causes acromegaly?
Acromegaly is caused by prolonged overproduction of growth hormone
by the pituitary gland. The pituitary is a small gland at the base of the
brain that produces several important hormones to control body
functions such as growth and development, reproduction, and
metabolism. Growth hormone is part of a cascade of hormones that, as
the name implies, regulates the physical growth of the body. This
cascade begins in a part of the brain called the hypothalamus, which
makes hormones that regulate the pituitary. One of these, growth
hormone-releasing hormone (GHRH), stimulates the pituitary gland to
produce growth hormone. Another hypothalamic hormone, somatostatin,
inhibits growth hormone production and release. Secretion of growth
hormone by the pituitary into the bloodstream causes the production of
another hormone, called insulin-like growth factor 1 (IGF-1), in the liver.
IGF-1 is the factor that actually causes the growth of bones and other
tissues of the body. IGF-1, in turn, signals the pituitary to reduce GH
production. GHRH, somatostatin, GH, and IGF-1 levels in the body are
tightly regulated by each other and by sleep, exercise, stress, food intake
and blood sugar levels. If the pituitary continues to make growth
hormone independent of the normal regulatory mechanisms, the level of
IGF-1 continues to rise, leading to bone growth and organ enlargement.
The excess GH also causes changes in sugar and lipid metabolism and
can cause diabetes.
Pituitary Tumors
In over 90 percent of acromegaly patients, the overproduction of growth
hormone is caused by a benign tumor of the pituitary gland, called an
adenoma. These tumors produce excess growth hormone and, as they
expand, compress surrounding brain tissues, such as the optic nerves.
This expansion causes the headaches and visual disturbances that are
often symptoms of acromegaly. In addition, compression of the
surrounding normal pituitary tissue can alter production of other
hormones, leading to changes in menstruation and breast discharge in
women and impotence in men.
There is a marked variation in rates of growth hormone production and
the aggressiveness of the tumor. Some adenomas grow slowly and
symptoms of growth hormone excess are often not noticed for many
years. Other adenomas grow rapidly and invade surrounding brain areas
or the sinuses, which are located near the pituitary. In general, younger
patients tend to have more aggressive tumors.
Non-pituitary Tumors
In a few patients, acromegaly is caused not by pituitary tumors but by
tumors of the pancreas, lungs, and adrenal glands. These tumors also
lead to an excess of growth hormone, either because they produce
growth hormone themselves or, more frequently, because they produce
GHRH, the hormone that stimulates the pituitary to make growth
hormone. In these patients, the excess GHRH can be measured in the
blood and establishes that the cause of the acromegaly is not due to a
pituitary defect. When these non-pituitary tumors are surgically removed,
GH levels fall and the symptoms of acromegaly improve.
In patients with GHRH-producing, non-pituitary tumors, the pituitary still
may be enlarged and may be mistaken for a tumor.
How common is acromegaly?
Small pituitary adenomas are common. During autopsies, they are found
in up to 25 percent of the U.S. population. However, these tumors rarely
cause symptoms or produce excessive GH or other pituitary hormones.
Scientists estimate that about 3 out of every million people develop
acromegaly each year and that 40 to 60 out of every million people suffer
from the disease at any time. However, because the clinical diagnosis of
acromegaly often is missed, these numbers probably underestimate the
frequency of the disease.
How is acromegaly diagnosed?
If a doctor suspects acromegaly, he or she can measure the growth
hormone level in the blood after a patient has fasted overnight to
determine if it is elevated. However, a single measurement of an elevated
blood growth hormone level is not enough to diagnose acromegaly,
because growth hormone is secreted by the pituitary in spurts and its
concentration in the blood can vary widely from minute to minute. At a
given moment, a patient with acromegaly may have a normal growth
hormone level, whereas a growth hormone level in a healthy person may
be five times higher.
Because of these problems, more accurate information can be obtained
when growth hormone is measured under conditions in which growth
hormone secretion is normally suppressed. Physicians often use the oral
glucose tolerance test to diagnose acromegaly, because ingestion of 75 g
of the sugar glucose lowers blood growth hormone levels less than 2
ng/ml in healthy people. In patients with growth hormone
overproduction, this reduction does not occur. The glucose tolerance test
is the most reliable method of confirming a diagnosis of acromegaly.
Physicians also can measure IGF-1 levels in patients with suspected
acromegaly. As mentioned earlier, elevated growth hormone levels
increase IGF-1 blood levels. Because IGF-1 levels are much more stable
over the course of the day, they are often a more practical and reliable
measure than GH levels. Elevated IGF-1 levels almost always indicate
acromegaly. However, a pregnant woman's IGF-1 levels are two to three
times higher than normal. In addition, physicians must be aware that
IGF-1 levels decline in aging people and may be abnormally low in patients
with poorly controlled diabetes mellitus.
After acromegaly has been diagnosed by measuring GH or IGF-1, imaging
techniques, such as computed tomography (CT) scans or magnetic
resonance imaging (MRI) scans of the pituitary are used to locate the
tumor that causes the GH overproduction. Both techniques are excellent
tools to visualize a tumor without surgery. If scans fail to detect a
pituitary tumor, the physician should look for non-pituitary tumors in the
chest, abdomen, or pelvis as the cause for excess GH. The presence of
such tumors usually can be diagnosed by measuring GHRH in the blood
and by a CT scan of possible tumor sites.
How is acromegaly treated?
The goals of treatment are to reduce GH production to normal levels, to
relieve the pressure that the growing pituitary tumor exerts on the
surrounding brain areas, to preserve normal pituitary function, and to
reverse or ameliorate the symptoms of acromegaly. Currently, treatment
options include surgical removal of the tumor, drug therapy, and
radiation therapy of the pituitary.
Surgery
Surgery is a rapid and effective treatment. The surgeon reaches the
pituitary through an incision in the nose and, with special tools, removes
the tumor tissue in a procedure called transsphenoidal surgery. This
procedure promptly relieves the pressure on the surrounding brain
regions and leads to a lowering of GH levels. If the surgery is successful,
facial appearance and soft tissue swelling improve within a few days.
Surgery is most successful in patients with blood GH levels below 40
ng/ml before the operation and with pituitary tumors no larger than 10
mm in diameter. Success depends on the skill and experience of the
surgeon. The success rate also depends on what level of GH is defined as
a cure. The best measure of surgical success is normalization of GH and
IGF-1 levels. Ideally, GH should be less than 2 ng/ml after an oral glucose
load. A review of GH levels in 1,360 patients worldwide immediately after
surgery revealed that 60 percent had random GH levels below 5 ng/ml.
Complications of surgery may include cerebrospinal fluid leaks, meningitis,
or damage to the surrounding normal pituitary tissue, requiring lifelong
pituitary hormone replacement.
Even when surgery is successful and hormone levels return to normal,
patients must be carefully monitored for years for possible recurrence.
More commonly, hormone levels may improve, but not return completely
to normal. These patients may then require additional treatment, usually
with medications.
Drug Therapy
Two medications currently are used to treat acromegaly. These drugs
reduce both growth hormone secretion and tumor size. Medical therapy
is sometimes used to shrink large tumors before surgery. Bromocriptine
(Parlodel®) in divided doses of about 20 mg daily reduces GH secretion
from some pituitary tumors. Side effects include gastrointestinal upset,
nausea, vomiting, light-headedness when standing, and nasal
congestion. These side effects can be reduced or eliminated if medication
is started at a very low dose at bedtime, taken with food, and gradually
increased to the full therapeutic dose.
Because bromocriptine can be taken orally, it is an attractive choice as
primary drug or in combination with other treatments. However,
bromocriptine lowers GH and IGF-1 levels and reduces tumor size in less
than half of patients with acromegaly. Some patients report improvement
in their symptoms although their GH and IGF-1 levels still are elevated.
The second medication used to treat acromegaly is octreotide
(Sandostatin®). Octreotide is a synthetic form of a brain hormone,
somatostatin, that stops GH production. This drug must be injected
under the skin every 8 hours for effective treatment. Most patients with
acromegaly respond to this medication. In many patients, GH levels fall
within one hour and headaches improve within minutes after the
injection. Several studies have shown that octreotide is effective for
long-term treatment. Octreotide also has been used successfully to treat
patients with acromegaly caused by non-pituitary tumors.
Because octreotide inhibits gastrointestinal and pancreatic function,
long-term use causes digestive problems such as loose stools, nausea,
and gas in one third of patients. In addition, approximately 25 percent of
patients develop gallstones, which are usually asymptomatic. In rare
cases, octreotide treatment can cause diabetes. On the other hand,
scientists have found that in some acromegaly patients who already have
diabetes, octreotide can reduce the need for insulin and improve blood
sugar control.
Radiation Therapy
Radiation therapy has been used both as a primary treatment and
combined with surgery or drugs. It is usually reserved for patients who
have tumor remaining after surgery. These patients often also receive
medication to lower GH levels. Radiation therapy is given in divided doses
over four to six weeks. This treatment lowers GH levels by about 50
percent over 2 to 5 years. Patients monitored for more than 5 years
show significant further improvement. Radiation therapy causes a gradual
loss of production of other pituitary hormones with time. Loss of vision
and brain injury, which have been reported, are very rare complications of
radiation treatments.
No single treatment is effective for all patients. Treatment should be
individualized depending on patient characteristics, such as age and
tumor size. If the tumor has not yet invaded surrounding brain tissues,
removal of the pituitary adenoma by an experienced neurosurgeon is
usually the first choice. After surgery, a patient must be monitored for a
long time for increasing GH levels. If surgery does not normalize hormone
levels or a relapse occurs, a doctor will usually begin additional drug
therapy. The first choice should be bromocriptine because it is easy to
administer; octreotide is the second alternative. With both medications,
long-term therapy is necessary because their withdrawal can lead to
rising GH levels and tumor re-expansion. Radiation therapy is generally
used for patients whose tumors are not completely removed by surgery;
for patients who are not good candidates for surgery because of other
health problems; and for patients who do not respond adequately to
surgery and medication.
Content Source NIDDK.NIH
| MEDICAL NOTES |
DISEASES AND
CONDITIONS
Acidosis
Acne
Acromegaly
Addison's Disease
Adrenal Crisis
Age. macular degn
Alzheimer's disease
Autoimmune
Hepatitis
Barrett's Esophagus
Cancer
Chronic Fatigue Syn.
Constipation
Colon Polyps
Crohns Disease
Cushing's Syndrm.
Diabetes
Erectile Dysfunction
Fecal Incontinence
Gallstones
Gastritis
Gastroenteritis
Gastroesophageal
Reflux (GERD)
Growth Hormone
Def.
Heartburn
Hemochromatosis
Hemorrhoids
Hyperparathyroidism
Hypertension
Inflam. Bowel Dis.
Kidney Stone
Liver Cirrhosis
Migraines
Multiple Sclerosis
Muscular Dystrophy
Obesity
Osteorithritis
Osteoporosis
Pancreatitis
Parkinson's Disease
Peyronies' Disease
Prolactinoma
Psoriasis
Scleroderma
Sprain and Strain
Stroke
Lupus Erthematosus
Ulcerative Colitis
Urin. Incontinence
Vitiligo
CONDITIONS
Acidosis
Acne
Acromegaly
Addison's Disease
Adrenal Crisis
Age. macular degn
Alzheimer's disease
Autoimmune
Hepatitis
Barrett's Esophagus
Cancer
Chronic Fatigue Syn.
Constipation
Colon Polyps
Crohns Disease
Cushing's Syndrm.
Diabetes
Erectile Dysfunction
Fecal Incontinence
Gallstones
Gastritis
Gastroenteritis
Gastroesophageal
Reflux (GERD)
Growth Hormone
Def.
Heartburn
Hemochromatosis
Hemorrhoids
Hyperparathyroidism
Hypertension
Inflam. Bowel Dis.
Kidney Stone
Liver Cirrhosis
Migraines
Multiple Sclerosis
Muscular Dystrophy
Obesity
Osteorithritis
Osteoporosis
Pancreatitis
Parkinson's Disease
Peyronies' Disease
Prolactinoma
Psoriasis
Scleroderma
Sprain and Strain
Stroke
Lupus Erthematosus
Ulcerative Colitis
Urin. Incontinence
Vitiligo