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Wise et al.
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aggravating factor. 139 In addition, preexisting AR can worsen in approximately one-third of pregnant women. 142 There are several etiologic factors potentially associated with the nasal symptoms in rhinitis of pregnancy. Hormonal changes, such as increased progesterone, estrogen, prolactin, vasoactive intestinal peptide, and/or placental growth hormone have been implicated, 143,144 but there is little evidence to support this theory. 145 Other physiologic phenomena occurring during pregnancy that may contribute to increased nasal congestion or obstruction include vasodilation, progesterone-induced smooth muscle relaxation, and a massive expansion of the circulating blood volume, which may contribute to increased nasal vascular pooling. 146 Rhinitis of pregnancy does not usually require therapy, nor does it respond well to standard allergy medications. Its management is made more difficult by the lack of high-quality studies on the efficacy of treatment and fetal out-comes. In those who seek treatment, conservative non-pharmacologic measures are suggested. These can include elevation of the head of the bed, 147 nasal dilator strips, 148 and exercise. 149,150 Saline lavage using hypertonic saline has been demonstrated to be effective without obvious deleterious effects on the fetus. 151 Several medications, including INCS, have been studied in rhinitis of pregnancy but have failed to demonstrate clear efficacy. 152 More recently, a systematic review by Kumar et al. 153 identified only 1 RCT that failed to demonstrate any additional benefit of fluticasone compared to placebo for symptom control in this patient population. Although an extensive discussion of rhinitis of pregnancy management is beyond the scope of this document, the use of various other medications (ie, topical and oral decongestants) is controversial and should be addressed at the individual patient level, with close involvement of the obstetrician. Direct stimulation of the nasal mucosa by estrogen may induce mucosal gland hyperactivity resulting in increased nasal secretions/rhinorrhea. 154 As such, nasal symptoms can be associated with conditions other than pregnancy that affect hormone balance, such as hypothyroidism and acromegaly. 155 Rhinitis may also arise as a result of changing blood hormone concentrations during puberty, menstruation, and the perimenopausal years. 145 Although oral contraceptives have also been implicated as causes of nasal symptoms, a study by Wolstenholme et al. 156 found no nasal physiologic effects in patients receiving oral contraceptive treatment. In summary, there are numerous metabolic conditions with symptoms like those of AR. Accurate diagnosis can be made on history and presentation, but additional testing may be required for symptoms that are persistent or severe. III.C.8. Food- and alcohol-induced rhinitis Food-induced rhinitis.: Certain food ingestions may result in rhinitis based on a nonimmunologic reaction, and therefore are not characterized as an allergy. For instance, in subjects with gustatory rhinitis, shortly after ingestion of hot or spicy foods, unilateral or bilateral watery rhinorrhea develops in the absence of nasal congestion, pruritus, or facial pain. This is considered a reflex response due to an adrenergic and cholinergic neural reaction of the nose. 157
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Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.
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