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A 39-year-old obese Russian female presents in 2016, after 10 days of copious vaginal bleeding that followed a 26-day delay in her menstrual cycle. The patient explains that she has been feeling generally weak, and has been experiencing recurrent periods of dizziness. As well, for the past year, she has had frequent episodes during which she feels sick, sweats profusely, and often faints. The patient's family medical history includes prostate cancer and thyroid disorders. She has given birth to two children, and has had no abortions. Her most recent pelvic examination, a few months prior to the present examination, did not reveal any pathology. The pelvic ultrasonography detected no pathology at that time. The patient tells you that her first menstrual period occurred when she was age 11; it lasted 5 to 6 days, with initially copious bleeding. After her first child was delivered, her periods became irregular, with abundant bleeding lasting 7 to 8 days. She notes that her menstrual cycles have been very irregular since she gave birth to her second child about 3 years previously, in 2013. Before her first pregnancy, the patient notes that she weighed 68 kg. She gained 28 kg during the pregnancies, and did not lose any weight thereafter. Current examination findings On clinical assessment, her weight is 106 kg, and her blood pressure is 215/126 mm Hg. Her mucous membranes appear pale, and her thyroid gland is slightly enlarged. Notably, she resides in an area where iodine deficiency is endemic. Gynecological examination reveals a slightly enlarged uterus that is painful on displacement; there is copious bloody discharge. Ultrasound of the abdomen and pelvis identifies moderate degrees of: Fatty liver infiltration Common bile duct dilation Wall thickening and heterogeneity of the gallbladder Lipomatosis of the pancreas Enlargement of the uterus The patient's ovaries are multifollicular, and there is a 25 X 16 mm cyst in her right ovary, which is enlarged. There is a small amount of fluid in the pouch of Douglas. Results of laboratory tests were normal, with the exception of results of the following blood tests: (PRL) Serum prolactin 1167 mIU/L (normal: 450–650 mIU/L) (TSH)Thyroid stimulating hormone 5.6 mIU/L (normal: 0.4–4.2 mIU/L) (FSH )Follicle stimulating hormone 10.6 mU/mL (normal: up to 9.9 mU/mL) (LH) Luteinizing hormone 19.6 mU/mL (normal: up to 15 mU/mL) She has mild dyslipidemia, with elevated total cholesterol of 6.81 mmol/L (normal 3.10–5.16) and atherogenic coefficient of 4.5 (normal 1.5–3). Historical evolution of symptoms 9 years prior (2007): Patient's beloved mother dies of stomach cancer, leaving her with intractable grief and regular dreams of her mother. The patient links this loss with the onset of her health problems. 8 years prior (2008): Hormonal imbalances develop, marked by increased levels of estrogen, follicle stimulating hormone, and prolactin. Patient undergoes surgical removal of endometrial polyps. 7 years prior (2009): Thyroid gland becomes enlarged. 5 years prior (2011): Gallstones develop. 4 years prior (2012): Kidney stones develop. 3 years prior (2013): Patient gives birth to her second child; when she stops breastfeeding, she begins to have irregular and heavy menses. She develops hypertension, chest pains, palpitations, and frequent loss of consciousness. Diagnosis and treatment path The patient is diagnosed with dysfunctional uterine bleeding with obesity, hypertension, and autonomic dysfunction with sympatho-adrenal crises. Consultation with an endocrinologist and a neurologist results in identification of various measures to manage the patient's overall poor health, and in particular, the excessive menstrual bleeding. Measures proposed by clinicians to stop the bleeding include curettage of uterine cavity, prescription of uterotonic drugs, and antibacterial therapy. (Leuprolide acetate is used for short-term treatment only.) The patient is also scheduled to start a weight loss program. However, in response to the patient's preference for a more natural approach to improving her health, the neurologist suggests she consult a professional homeopath to see if an alternative solution is available. Treatment and 0utcome On October 10, 2016, the homeopath assesses the patient's current health status. Included in his considerations is the prolonged grief that the patient has been experiencing since the death of her mother, which he believes plays a major role in her complicated medical status. She begins taking the homeopathic remedy without any other medication, and continues with the same diet and routine as she had been practicing. 10/10/2016 Tx: Natrum muriaticum 15C on alternate days. Dosage is later increased to 21C and 30C as required. 19/12/2016 Tx: Natrum muriaticum 60C Patient's mood, sleep, and pre-menstrual syndrome symptoms are much improved. She develops boils with pus discharge on the forehead and on the right thigh, which disappear on their own. 27/03/2017 Tx: Ignatia 200C Within 5 months of beginning the treatment, the sympatho-adrenal crises are resolved. The patient's homeopathic remedy is changed to Ignatia 200C due to a change in the symptom indication. The patient has lost 4 kg. She reports an increase in blood pressure and exhaustion due to work-related stress, but she is able to cope without any medicine. 30/10/2017 Tx: Nil At last follow-up, 12.5 months after starting the homeopathic remedy, the patient reports that her quality of life is greatly improved; she feels better mentally, emotionally, and physically. Her sleep is refreshing and good. She no longer has dizziness, loss of consciousness or palpitations, or profuse sweating. Her menstrual cycles are now regular and painless, and she has no PMS. Her pelvic ultrasound scan is normal. Her body weight is 82 kg. Biomarker evolution, baseline to last follow-up Serum prolactin: 1,167 mIU/L to 578 mIU/L Thyroid (TSH): 5.6 mIU/L to 3.4 mIU/L Follicle stimulating hormone: 10.6 mU/mL to 7.6 mU/mL Luteinizing hormone: 19.6 mU/mL to 7.8 mU/mL Blood pressure (24-hour): 215/126 mm Hg to 135/93 mm Hg Total cholesterol: 6.81 mmol/L to 4.73 mmol/L Atherogenic coefficient: 4.5 to 1.8 Hemoglobin: 86.4 g/L to 126.7 g/L Discussion Clinicians reporting this unusual Russian case1 suggest that it is the first to describe the specific association of obesity, hypertension, hormonal imbalances, dysfunctional uterine bleeding, and dysautonomia treated with homeopathy. They propose that autonomic nervous system dysfunction, which seemed to be central to all of the patient's suffering, was triggered by the severe griefrelated stress she experienced following her mother's demise. This may have upset the patient's sympatho-vagal balance, resulting in her obesity, hypertension, hormonal disruption, and related symptoms. While reports of autonomic dysfunction are scarce in general medical literature, the condition is often reported in the Russian medical literature, they note.2,3 It involves sudden malfunction of the autonomic nervous system with panic attack-like episodes associated with vasodilatation and loss of consciousness. Although its etiology is considered mostly psychogenic, it can have a significant and real impact on the quality of life of those affected.4 This case reflects a previously reported link between the autonomic nervous system functioning and body mass index,5 as well as the wellknown link between inflammation and obesity. Notably, case authors acknowledge that obesity can be caused simply by excess energy intake and addressed with diet and lifestyle changes. However, obesity can also result from alteration of the hypothalamic pituitary-adrenal axis through emotional stress.6-8 Classical homeopathic theory9 holds that the immune system's defense against disease or other insult is central to determining treatment, case authors explain. The homeopathic practitioner must determine what triggered the patient's chronic inflammatory state. Then, based on an individual's immunological make up, and medical and family histories, they aim to select a treatment that allows the person's own immune system to resolve the inflammatory state, with additional benefits to the individual's overall health. They note that chronic low-grade inflammation in the body can lead not only to obesity,10 but may also trigger various other inflammatory states such as metabolic syndrome, depression, and cardiovascular diseases. Case authors acknowledge that the mechanism of action of homeopathic remedies is not well understood. The remedies used in this case are known to help restore balance in conditions such as depression that result from grief and bereavement.11 Natrum muriaticum is sodium chloride, or common (primarily sea) salt, while Ignatia comes from the seeds of the St. Ignatius bean tree.12 Evidence is not strong enough to clearly support results for this homeopathic remedy. However, they write, such overall improvement from a therapy, especially without changes in any other parameter that may have caused the improvements, is encouraging. Controlled randomized trials are needed to establish the relevance of classical homeopathy in obesity and its comorbidities and in autonomic dysfunction as well.