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Haematological Isolated red cell macrocytoisis Macrocytic anaemia (especially if MCV more than 110fl) Pancytopenia (especially if MCV more than 120fl) Neurological or Psychiatric Optic neuropathy Peripheral neuropathy (sensory or motor) Symmetrical neuropathy affecting the legs more than the arms

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Stress, chronic illness, and breastfeeding are also common reasons for delayed or missed periods, as they can impact hormonal balance and reproductive health

Vitamin B supplementation can be needed in some cases, but injectable therapy should be based on confirmed deficiency or clinical need

Oral treatment generally requires four to six weeks before noticeable improvements occur , and compliance is essential for success

Serum electrolytes, particularly potassium should be monitored closely - Anticoagulants: can increase or decrease the effects being necessary a dosage adjustment - Somatotropin: by inhibiting the response to this hormone Pregnancy and lactation Pregnancy: Safe use of this medicine in pregnancy has not been established