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A 32-year-old woman with classical congenital adrenal hyperplasia (CAH) secondary to 21-hydroxylase deficiency presented with infertility. She was treated with different steroid replacement regimens together with fludrocortisone. The aim of this case report is to discuss fertility barriers in women with classical CAH, and emphasise the risks and benefits of available steroid treatment options. Clinical considerations covered include preconception health and fertility planning, optimising fertility through suppression of excess hormone production, reducing fetal androgen exposure in utero and limiting maternal and fetal side effects of therapy and limiting chances of CAH in the baby. In this case suppression of androgen and progesterone levels was challenging but eventually was achieved and resulted in a spontaneous pregnancy. However, she miscarried in the first trimester, and fetal biopsy revealed a complete hydatiform mole. She is advised not to conceive while she is under investigation to determine the extent of the disease.

A 32-year-old woman with classical congenital adrenal hyperplasia (CAH) secondary to 21-hydroxylase deficiency presented with infertility. She was treated with different steroid replacement regimens together with fludrocortisone. The aim of this case report is to discuss fertility barriers in women with classical CAH, and emphasise the risks and benefits of available steroid treatment options. Clinical considerations covered include preconception health and fertility planning, optimising fertility through suppression of excess hormone production, reducing fetal androgen exposure in utero and limiting maternal and fetal side effects of therapy and limiting chances of CAH in the baby. In this case suppression of androgen and progesterone levels was challenging but eventually was achieved and resulted in a spontaneous pregnancy. However, she miscarried in the first trimester, and fetal biopsy revealed a complete hydatiform mole. She is advised not to conceive while she is under investigation to determine the extent of the disease.

Sertraline is widely prescribed to treat depression and anxiety disorders. However, hepatitis secondary to its use is a rare entity. We report the case of a 26-year-old woman in her 20th week of pregnancy presented with nausea, vomiting, malaise and dark urine. This occurred 6 months after sertraline 50 mg daily was started for the treatment of depression. Three weeks prior to her presentation, the dose of sertraline was increased to 100 mg daily. The patient's liver biochemical profile demonstrated increased transaminases. The biopsy of the liver showed lobular hepatitis, with a mild prominence of eosinophils, suggestive of a drug-induced or toxininduced aetiology. Extensive biochemical work-up failed to show any other pathology to account for her hepatitis. Liver function tests normalised after cessation of sertraline, indicating a probable association between sertraline use and acute hepatocellular injury in our patient.

Background: Reduced high-density lipoprotein cholesterol (HDL-C) concentration is considered to be an independent risk factor for cardiovascular morbidity and mortality. Fibrates are useful in managing dyslipidaemia; reports highlight an expected increase in HDL-C of 10-15% in conjunction with falls in plasma triglycerides of ~30%. Despite this, there are several reported cases of paradoxical decreases in HDL-C caused by fibrate treatment. Aim(s): To report the second largest observational study to date. Method(s): Fenofibrate use at a regional lipid clinic was associated with reductions in HDL-C in a considerable proportion of patients, necessitating cessation of the medication. In view of this, characteristics of the first 94 patients to be given fenofibrate were retrospectively analysed, and comparisons were made between those whose profiles responded as expected and those experiencing paradoxical decreases in HDL-C. Result(s): 94 patients (57 male; mean (SD) age 52.5 (12.5) years; mean (SD) body mass index 28.9 (4.5) kg/m2) were assessed. After 8-12 weeks on daily fenofibrate (200 mg micronised or equivalent), 43 of the patients (46%) showed a paradoxical decrease in HDL-C (in nine the decrease was >50% from baseline). When responses to fenofibrate were compared against baseline variables, there were no significant differences between groups other than a higher baseline HDL-C (p = 0.045) in patients responding appropriately. Conclusion(s): Fenofibrate was associated with a reduction in HDL-C in almost half the patients studied. This is substantially more than in most studies reported to date. Other HDL-C-raising strategies need to be considered in these patients, and the mechanisms need to be explored.

Background: Reduced high-density lipoprotein cholesterol (HDL-C) concentration is considered to be an independent risk factor for cardiovascular morbidity and mortality. Fibrates are useful in managing dyslipidaemia; reports highlight an expected increase in HDL-C of 10-15% in conjunction with falls in plasma triglycerides of ~30%. Despite this, there are several reported cases of paradoxical decreases in HDL-C caused by fibrate treatment. Aim(s): To report the second largest observational study to date. Method(s): Fenofibrate use at a regional lipid clinic was associated with reductions in HDL-C in a considerable proportion of patients, necessitating cessation of the medication. In view of this, characteristics of the first 94 patients to be given fenofibrate were retrospectively analysed, and comparisons were made between those whose profiles responded as expected and those experiencing paradoxical decreases in HDL-C. Result(s): 94 patients (57 male; mean (SD) age 52.5 (12.5) years; mean (SD) body mass index 28.9 (4.5) kg/m2) were assessed. After 8-12 weeks on daily fenofibrate (200 mg micronised or equivalent), 43 of the patients (46%) showed a paradoxical decrease in HDL-C (in nine the decrease was >50% from baseline). When responses to fenofibrate were compared against baseline variables, there were no significant differences between groups other than a higher baseline HDL-C (p = 0.045) in patients responding appropriately. Conclusion(s): Fenofibrate was associated with a reduction in HDL-C in almost half the patients studied. This is substantially more than in most studies reported to date. Other HDL-C-raising strategies need to be considered in these patients, and the mechanisms need to be explored.