The dangers of misusing Vitamin A: What every woman should know

Clarise* was on the other end of the phone sobbing. She had been seeing me for a few years now for various gynaecological issues after a referral from her dermatologist to find out whether her acne problems had anything to do with polycystic ovarian syndrome (PCOS).

Other than the acne, Clarise had no other symptoms to indicate PCOS. She now came in for her contraceptive needs, regular screening for cervical cancer and treatment of minor gynaecological issues.

Two years ago, the dermatologist needed to step it up a notch with her skin issues and this included the use of isotretinoin creams. She instructed her to ensure she was on a contraceptive.

At this time, Clarise had ended a three-year relationship and had no desire to get back into one any time soon. She tried bargaining with me about it but I was firm that should anything happen and she got intimate and conceived, the isotretinon posed a very high risk to the baby.

She grudgingly left the office with a pack of the contraceptive skin patch. What Clarise did not tell me was that she never used the patch. She went on to start the isotretinoin cream, prescribed for three months. I did not see Clarise again until the call. This was almost four months after her last visit.

She had missed her period and was scared she could be pregnant. She was panicked because right up to two weeks prior, she had been on her isotretinoin cream. She had not planned on having a sexual relationship but a night of indulgence and not-so-smart decisions led to her current predicament.

Clarise was three days late, but for someone whose cycle was a strict 26 days, she was a step away from a panic attack. It took some minutes to calm her down and point out the obvious; she had not even taken a pregnancy test! I did caution her of the likelihood of a negative test and the need to repeat the test a few days later.

Her first test was negative but it did little to calm her down. However, she could settle down for the week and focus on other things while we waited for the next week. Thankfully we did not get to the next week, two days after the first test, Clarise’s period came. She booked the next immediately available appointment and came for an intrauterine contraceptive device.

Why was Clarise so anxious? It wasn’t about being pregnant; it was all about the risk of isotretinoin on the developing baby. Isotretinoin is a vitamin A subtype. Vitamin A has two subtypes: preformed vitamin A, the metabolically active version that includes retinol and retinoic acid, and is derived from animal sources such as egg yolk, butter, chicken, beef, organ meats, and fish; and pro-vitamin A carotenoids, which are metabolized by the body into active compounds and are derived from plant pigments in leafy greens, carrots, sweet potatoes, and papayas.

Vitamin A’s main functions in the body include supporting the multiplication of cells in the body, especially concerning vision, reproduction and immunity. With a regular diet, it is quite difficult to consume excessive vitamin A which will result in hypervitaminosis A.

However, in certain conditions such as consumption of vitamin supplements, and in certain medications that contain high levels of vitamin A, vitamin A toxicity can result.

This toxicity can be acute, meaning a sudden high level of vitamin A in the body; or chronic, where there is daily, long-term consumption of increased vitamin A, that sustains elevated vitamin A in the body over a prolonged period.

A publication by Hunt JR. on the teratogenicity of high vitamin A intake, where acute toxicity happens, commonly occurs in situations such as an overdose of Vitamin A supplements, especially in children. The patient develops nausea, vomiting, headache, dizziness, blurring of vision, muscular incoordination, mouth sores, and dry lips, mouth, nose and ears.

The chronic version of the toxicity results in the gradual onset of symptoms, which include nausea, vomiting, headache, dry and cracked skin, hair loss, brittle nails, fatigue, loss of appetite, bone and joint pains, osteoporosis, fractures, liver damage, high blood calcium levels that can cause convulsions and kidney stones, and kidney failure.

Hypervitaminosis A has been known to cause congenital abnormalities in the unborn baby for the last seven decades or so. Another study shows that the baby may have abnormalities of the brain such as hydrocephalus (abnormally large head with excessive cerebrospinal fluid), microcephaly (abnormally small head); abnormalities of the heart and large blood vessels; cleft lip and palate; limb abnormalities; and urinary tract disorders.

Treatment is essentially based on stopping the continued exposure to the vitamin A source of toxicity and supporting the patient with relief of symptoms such as pain medication, fluids, emollients, and medication to reduce the excess calcium.

Clarise had every right to be worried about the possibility of being pregnant with a baby that may be born with severe and life-threatening conditions. This was the basis for the dermatologist being extremely cautious with her, and insisting on birth control before the initiation of treatments with vitamin A components.

With the hype for great skin, especially among younger women, this must be done under professional care to avoid such complications, borne out of ignorance. Vitamin A is a necessary component for our overall well-being, but when abused, it is not forgiving!

Dr Bosire is a gynaecologist/obstetrician