Burkin > Estrogens & Progestins Flashcards
1
Q
what is a combined oral contraceptive?
A
hormonal contraceptive administered orally that contains estrogen & a progestin
2
Q
what is HRT?
A
hormone replacement therapy
3
Q
what is MHT?
A
menopausal hormone therapy
4
Q
what is a SERM?
A
selective estrogen receptor modulator
5
Q
what tissues does estrogen affect (7)?
A
heart & liver brain bone breast ovary uterus vagina
6
Q
what are estrogen’s effects on the brain (3)?
A
- maintain body temp
- delay memory loss
- prep for sexual & repro dvlpmnt
7
Q
what are estrogen’s effects on the heart & liver?
A
regulate cholesterol production > dec plaques in coronary arteries
8
Q
what are estrogen’s effects on the ovary?
A
- stimulate maturation
2. stimulate start of menstrual cycle
9
Q
what are estrogen’s effects on the vagina?
A
- stimulate maturation
2. maintain lubricated & thick vaginal lining
10
Q
what are estrogen’s effects on the breast?
A
- stimulate development at puberty
2. prep glands for future milk pdtion
11
Q
what are estrogen’s effects on the uterus?
A
- stimulate maturation
2. prep the uterus for a fetus
12
Q
what are estrogen’s effects on the bone?
A
preserve bone density
13
Q
what are the 2 broad therapeutic indications for estrogens?
A
- contraception
2. hormone replacement regimens
14
Q
what are 4 instances where hormone replacement regimens may be appropriate?
A
- menopause
- hypogonadism
- dysfxnal uterine bleeding
- combo w/ androgens to promote growth
15
Q
what are 2 clinical applications of antiestrogens?
A
- infertility
2. breast cancer
16
Q
what does 3-b-hydroxysteroid dehydrogenase do?
A
converts pregnenolone to progesterone
pregnenolone has 3 ns
17
Q
what does 17-b-hydroxysteroid dehydrogenase do?
A
converts estrone to estradiol
&
converts androstenedione to testosterone
18
Q
what does aromatase do?
A
converts androgens to estrogens
19
Q
what are the 3 classes of estrogens available for therapeutic use?
A
- natural
- synthetic steroidal
- synthetic non-steroidal
20
Q
what are the 3 natural estrogen preparations?
A
estradiol
estrone
estriol
21
Q
what is essential about the natural estrogen preps?
A
phenolic A ring
22
Q
how does aromatase convert androgens to estrogens?
A
catalyzes aromatic hydroxylation of the A ring of C19 androgens to form estrogens
23
Q
what can convert estradiol & estrone into estriol?
A
16α-hydroxylase in the liver
24
Q
are natural estrogen preps orally active?
A
nope
extensive 1st pass metabolism
25
what is ESTRADERM?
transdermal estradiol patch that provides slow sustained release
26
why would you use transdermal estradiol?
lower hepatic exposure, less metabolism
| you can reach therapeutic levels of estradiol at lower circulating levels of estrone & estriol
27
what are the 3 classes of synthetic steroidal estrogens?
1. estradiol esters
2. conjugated estrogens
3. alkyl estrogens
28
which synthetic steroidal estrogens are the most potent?
alkyl estrogens
29
name the 2 estradiol esters
estradiol valerate
| estradiol cypionate
30
what is notable about the structure of estradiol esters?
have short chain fatty acids at C17
31
how do you give estradiol esters?
dissolve it in oil & inject it IM
| *poor oral bioavailability
32
how long does the effect of estradiol esters last?
several weeks
| takes a while to kick in though
33
name 2 conjugated estrogens
1. estrone sulfate
| 2. equilin sulfate
34
what routes can you use for conjugated estrogens?
1. oral
2. parenteral
3. topical
35
what happens to conjugated esters in the intestine?
they are hydrolyzed to remove sulfate groups & allow absorption
36
when would you use an oral conjugated estrogen?
for menopausal HRT
37
when would you use an IV conjugated estrogen?
for emergency treatment of dysfxnal uterine bleeding
38
what are the 2 alkyl estrogens?
1. mestranol
| 2. ethinyl estradiol
39
what are the most potent steroidal estrogens & why?
```
alkyl estrogens (mestranol)
d/t increased affinity for ER
```
40
why is first pass metabolism of alkyl estrogens inhibited?
ethinyl substitution at C17
41
mestranol is a pro-drug of what?
ethinyl estradiol
42
how is mestranol activated?
removing the C3 methyl group
43
when do you use alkyl estrogens?
oral contraception
44
which class of estrogens is no longer used clinically?
synthetic non-steroidal estrogens
45
name the synthetic non-steroidal estrogens (3)
1. Diethylstilbestrol
2. chlorotrianisene
3. methallenestril
46
why is diethylstilbestrol important?
it was a cheap, oral estrogen used for endocrine therapies when natural pdts were unavailable
47
what types of synthetic agents have estrogenic or antiestrogenic properties?
polycyclic compounds w/ phenolic rings resembling the steroid A ring
48
what are 3 examples of synthetic agents that have estrogenic or antiestrogenic properties?
1. pesticides
2. plasticizers (bisphenol A)
3. industrial chemicals (polychlorinated biphenyls)
49
what are the 2 natural progestins?
1. P4
| 2. 17α-hydroxyprogesterone
50
what structure is favored by the progesterone receptor & recognized by other steroid receptors?
C21 structure
51
how is P4 administered?
IM as an oil soln
52
what is the main side effect of P4 administration?
injection site has local irritation
53
what are the 2 structures of synthetic progestins?
1. C21
| 2. C19
54
what can you do to a C21 synthetic progestin to reduce hepatic metabolism?
substitute an ester at C17
55
which synthetic progestin is more selective for PR: C21 or C19?
C21
56
which synthetic C21 progestin can you administer IM?
hydroxyprogesterone caproate
57
which synthetic C21 progestin can you administer orally?
MPA > medroxyprogesterone acetate
58
what are synthetic C19 progestins derived from?
C19 nor-testosterone
59
which synthetic progestin has more androgenic activity: C19 or C21?
C19
60
what are the uses for synthetic C19 progestins?
oral & implantable contraception
61
what are the 2 MAJOR uses of progestins?
1. contraceptives (alone)
| 2. HRT (in combo w/ estrogen)
62
what are the 4 MINOR uses of progestins?
1. dysmenorrhea
2. endometriosis
3. hirsutism
4. uterine bleeding
63
what is menopause?
permanent end of menstruation & fertility
| 12 months after LMP
64
what is the average age of menopause in the US?
51 yo
65
what is the average age of perimenopause?
47 yo
66
how long before menopause do you get perimenopause?
2-8 years
| avg = 4 yrs
67
how much does smoking accelerate the transition from perimenopause to menopause?
2 years
68
how do the symptoms of perimenopause work?
may begin at mid-level intensity
| may come & go unpredictably for months or years
69
what are the sx of perimenopause (there are a lot)
```
fatigue
weight gain
loss of libido
depression
hot flashes
night sweats
mood swings
vaginal dryness
irritability
```
70
what are estradiol levels of perimenopausal women like?
can be higher conc than in women under 35 yo
71
what are the early physiological changes of perimenopause (hormonal)?
DEC inhibin > INC FSH > INC ovarian follicular response > INC estrogen
72
what is the most common cause of erratic bleeding?
anovulation
73
what % of pts have irregular menses?
>50%
74
make sure you look at that picture of the menstrual cycle
okay
75
when can you discontinue contraception in ALL women?
at 55 yo
76
if a woman has abn uterine bleeding, what should you suspect?
endometrial cancer
77
what is the overall incidence of endometrial cancer?
0.1%
78
what is the risk of endometrial cancer if a woman has abn uterine bleeding?
10%
79
how long do hot flashes last?
1-5 minutes
80
how many women are affected by hot flashes?
up to 60%
81
why does skin temp rise in a hot flash?
peripheral vasodilation
82
what are the sx of a hot flash (other than hot skin)
```
inc systolic BP
inc HR
palpitations
anxiety
irritability
panic
```
83
what can happen if you withdraw or rapidly fluctuate estrogen levels?
NT levels &/or fxn are affected
| beta endorphins
84
what receptors do estrogens modulate?
adrenergic (specifically NE)
85
what happens to the temp set point during menopausal transition?
DEC estrogen > unstable set point > altered response to external stimuli
over time, the set point becomes stable again (or you can use exogenous hormones to help)
86
what receptor is out of whack during menopausal transition?
hypothalamic serotonin 5-HT2A receptor
87
what are the risk factors for hot flashes & menopause side FX?
surgical menopause
race/ethnicity
smoking
body mass
88
what happens to follicles & ovulation during late menopausal transition?
impaired folliculogenesis
| INC anovulation
89
why is there impaired folliculogenesis in late menopause?
FSH levels rise > ovarian follicles undergo accelerated rate of loss until all the follicles are depleted > FSH levels keep rising
90
WHY do FSH levels rise in late menopause?
aging follicles can't secrete inhibin > INC FSH levels
| d/t no estrogen
91
how long is a woman considered post-menopausal?
from the moment menopause occurs until she DIES
92
T/F: all the sx assoc w/ menopause disappear once post-menopause begins
FALSE
93
what are the sx of post-menopause?
```
BONE LOSS
vaginal dryness
weight gain
stress incontinence
UTIs
insomnia
occasional hot flashes
```
94
what is osteoporosis?
a skeletal disorder that compromises bone strength d/t progressive reduction in bone mass
95
what is the precursor to osteoporosis?
osteopenia
96
what is a major indicator for HRT?
osteoporosis
97
what hormone prevents bone loss?
estrogen
98
which cells control bone formation?
osteoblasts
99
which cells control bone resorption?
osteoclasts
100
why is osteoclast formation limited in premenopausal women?
E1 limits RANKL expression from osteoblasts > limits osteoclast formation
101
why do postmenopausal women have increased osteoclast numbers, activity, & life span?
DEC E2 > INC RANKL expression > INC osteoclasts
102
what imbalance is involved in bone loss?
formation vs resorption
103
what is the leading cause of death in women?
CVD
104
what can help maintain favorable lipid profiles in women?
estrogen
105
where is fat deposited that leads to weight gain in postmenopausal women?
abdomen
106
what does INC abdominal fat lead to in women?
HIGHER total cholesterol, triglys, & LDL
| LOWER HDL
107
what are the 3 management options for menopause?
1. HRT
2. lifestyle changes
3. alternative remedies
108
what particular sx, not related to osteoporosis, may respond to estrogen treatment?
atrophic vaginitis
irritability
anxiety
fatigue
109
what do HRT regimens usu include?
low dose estrogen + progestin
| in women w/ a uterus
110
what do you give (HRT) for perimenopause?
oral contraception: static doses of estrogen & progestin (i.e. ethinyl estradiol + norethindrone acetate)
111
what FX are you looking to achieve w/ HRT in perimenopause?
1. eliminate vasomotor sx
2. restore regular cyclicity
3. protect against ovarian & endometrial cancer
4. inc bone density
5. contraception
112
what are the contraindications of HRT in perimenopause?
```
cigarette smoking
liver dz
hx of thromboembolism or CVS dz
breast cancer
unexplained vaginal bleeding
```
113
which one requires lower doses of estrogen & progestin: perimenopause or postmenopause?
post
114
what makes a woman more likely to choose HRT?
if they are healthy
have better access to medical care
are more compliant
maintain a more health-promoting lifestyle
115
what was the turning point for HRT?
the 2002 WHI study of Prempro that showed inc risk of CVS events, inc risk of dementia, & inc risk of ovarian cancer
116
how does HRT affect breast cancer? (2002 WHI study showed)
increases risk
| makes it harder to detect
117
what are the CURRENT GUIDELINES for MHT/HRT?
prescribe hormone therapy to treat sx for the shortest period of time possible
118
why shouldn't you give estrogen by itself?
it can lead to uncontrolled endometrial proliferation
119
what 2 things do you actually DECREASE your risk for if you take HRT?
colorectal cancer & hip fx
120
what test results confirm that a woman is postmenopausal?
high FSH
high LH
low estrogen
121
what are the estrogen receptors?
ER alpha
| ER beta
122
what theory evolved to help explain why estrogen has effects on numerous organs?
hormone selectivity theory
123
where is ER alpha (what tissues)?
uterus & ovary
testes & epididymis
pituitary
adrenal gland & kidney
124
where is ER beta (what tissues)?
```
testes & prostate
uterus & ovary
lung
bladder
brain
```
125
what do SERMs do?
cause estrogenic effects where you want them, and non-estrogenic activity in cells where you don’t want them
126
what does SERM stand for?
selective estrogen receptor modulators
127
what is the prototypical & BEST SERM?
Raloxifene
| Raloxifene rox
128
what receptors does raloxifene bind?
ERalpha & ERbeta
129
what does raloxifene do in bone & CVS?
agonist
130
what are raloxifene's actions on bone?
INC bone density
| DEC fx
131
what are raloxifene's actions on cholesterol?
DEC total cholesterol
132
what does raloxifene do in the uterus & breast?
it's an antagonist
133
how does raloxifene impact overall cancer incidence?
50%+ decrease in cancer incidence
134
what about raloxifene makes it as good as estrogen for bone density & lipoprotein profiles, but w/o the side FX that estrogen has?
the unique agonist/antagonist activity
135
why is raloxifene better than estrogen?
raloxifene doesn't have the adverse FX on endometrial & breast tissue & doesn't inc risk of breast or uterine cancer
136
what are the 3 side FX of raloxifene?
hot flashes
leg cramps
blood clots
137
what are the 4 contraindications for raloxifene?
pregnant/breastfeeding women
premenopausal women
hx of thromboembolic events/stroke
smoking
138
what is ospemifene used for?
dyspareunia (painful sex)
139
what is ospemifene?
SERM w/ estrogenic effects on vaginal epithelium
140
what would the IDEAL SERM do?
1. prevent fx
2. reduce menopausal sx
3. treat vaginal atrophy
4. be neutral or protective on the uterus, breast, & CVS
141
is there an ideal SERM?
nope, not yet
142
T/F: conventional hormone therapy is preferred over compounded
TRUE
143
is there evidence that bioidentical hormones are superior?
nope
144
what are 2 alternative therapies for menopause?
1. phytoestrogens
| 2. black cohosh
145
what does black cohosh maybe help w/?
short term treatment of hot flashes & vaginal dryness
146
what are phytoestrogens?
substances found in plant-based foods that have weak estrogenic effects
147
what do phytoestrogens maybe help w/?
lowering cholesterol
| relieving hot flashes
148
what is genistein?
a natural phytoestrogen
149
what receptor does genistein work at?
higher affinity for ERbeta
150
what does genistein do (what are its physiological FX)?
1. stimulate bone formation
2. inhibit bone resorption
3. prevent bone loss
4. lower LDL & triglys
5. help relieve hot flashes
151
what is genistein's effect on cancer?
LOW DOSE: inhibit prostate, cervical, brain, colon, & breast cx
HIGH DOSE: inc rate of growth of some ER-dependent breast cx
152
how does genistein interact w/ tamoxifen & aromatase inhibitors?
reduces efficacy
153
what does genistein do to the thyroid?
depress fxn > infertility (who cares if you are already in menopause though?)
154
what are the lifestyle factors you can do to help w/ menopause?
1. get good sleep
2. exercise
3. decrease stress & maintain a schedule
4. limit booze, drugs, cigs
5. eat well
6. sun, vitamin D, Ca
7. drink enough water in the early part of the day
155
what is the action of antiestrogens?
competitive antagonists
precisely: partial agonists
of the estrogen receptor
inhibit estrogen synthesis
156
why does clomiphene citrate have a long half life of 5-7 days?
plasma protein binding
hepatic recycling
accumulation in fatty tissue
157
where is clomiphene citrate less active as an antiestrogen?
in the periphery
158
what is the treatment of choice for postmenopausal women w/ breast cancer?
tamoxifen
| usu in combo w/ surgery & chemo
159
where is tamoxifen less active as an antiestrogen?
at the pituitary
160
in premenopausal women, what is used to decrease ovarian estrogen synthesis?
oophorectomy
or
tx w/ GnRH analogs (leuprolide)
161
what is the preferred adjuvant tx for postmenopausal women w/ localized or metastatic ER+ breast cancer?
anastrozole
162
what should you combine exemestane w/?
Everolimus (Afinitor) which is an mTOR inhibitor
163
what are the 6 hormonal birth control methods?
1. pills
2. injections
3. skin patches
4. subdermal implants
5. vaginal rings
6. IUDs
164
what is the PRACTICAL efficacy of oral contraceptives?
97-98%
165
T/F: OCs are available as mono, bi, or tri phasic
true
166
if you have a combination hormonal contraceptive, what's in it?
an estrogen & a progestin
167
what are the 2 types of OC?
combination
AND
progestin only
168
what is the primary MOA of combination OC pills?
suppress FSH & LH secretion via negative feedback
| i.e. suppress ovulation
169
what does progestin stimulate in the cervix?
thick viscous mucus > reduces sperm penetration
170
what do combo OCs do to the endometrium?
make it not receptive to implantation
171
what do monophasic combo pills have?
fixed amts of hormones
| 21 days on, 7 days off
172
what do biphasic & triphasic combo pills do?
DEC total amt of steroids administered
| more closely approximate the menstrual cycle
173
what is special about extended cycle pills?
they let women have fewer periods
174
T/F: women who take OCs don't have "true" periods
TRUE
175
what is the point of having a period if you are on OCs?
reassure a woman that she isn't pregnant
| no medical fxn
176
if you take Seasonale or Seasonique, how many periods a year do you have?
4
177
if you take Lybrel, how many periods a year do you have?
NONE! amazing!
178
what drugs can interrupt enterohepatic cycling & diminish OC efficacy?
ABX!
179
what happens to estrogens in the liver?
they undergo either sulphation or glucuronidation
180
how do estrogen conjugates get to the small intestine from the liver?
bile duct
181
what happens to estrogen conjugates once they get to the small intestine?
intestinal bacteria break the conjugates down > release free, active estrogenic hormone
182
what is responsible for plasma estrogen levels necessary for contraception?
enterohepatic cycling
183
how often do you apply the patch?
weekly
184
where do you put the patch?
upper outer arm, butt, abs, or thigh
185
what hormones are in the patch?
combo
| ethinyl estradiol & norelgestromin
186
why do combo pills reduce the incidence of endometrial cancer?
bc progestin is anti-proliferative
187
what are the 2 potential benefits of contraceptives?
dec incidence of endometrial & ovarian cancers
188
T/F: combo contraceptives are assoc w/ inc breast cancer rates
FALSE
189
what are the contraindications of combo contraceptives?
hepatic dz
suspected pregnancy
undx vaginal bleeding
smokers >35 yo
190
what is NuvaRing?
flexible plastic ring that releases a low dose of ethinyl estradiol & progestin (etonogestrel) over 3 wks
191
what reduces the efficacy of NuvaRing?
if the ring is removed or accidentally expelled for 3+ hours
192
what was drosperinone approved for?
moderate acne & premenstrual dysmorphic disorder
193
why was drosperinone withdrawn?
inc thrombo 6-7x
| risk of hyperkalemia
194
what is a mini-pill?
progestin-only low dose contraceptives
195
how do mini-pills affect natural estrogen levels?
they don't!
196
T/F: the FDA recommends mini-pills during breastfeeding
FALSE
| they CAN be taken during breastfeeding, but the FDA doesn't recommend ANY hormonal contraception during breastfeeding
197
why are mini-pills effective?
thickening of cervical mucus
198
are mini-pills affected by abx?
nope
| not dependent on gut bacteria for absorption
199
what are the side FX of mini-pills?
can affect lipid profile
| thrombo
200
what does a mini-pill cause in a dog but not in a person?
breast tumors
201
why is medroxyprogesterone acetate effective?
thickening of cervical mucus
202
how fast does a depo shot (medroxyprogesterone) provide protection?
instantly
203
how long can you use depo (medroxyprogesterone)?
2 years
| concerns over bone loss
204
what is norplant?
implanted silicone capsules filled w/ levonorgestrel
205
what drug do IUDs use?
levonorgestrel
206
how long do IUDs work?
5 years
207
T/F: IUDs are irreversible
FALSE
208
what do IUDs decrease the risk of?
cervical cancer
209
when is the critical period for exposure to contraceptives in utero?
2-9 weeks post-fertilization
210
what is the guideline on contraceptives during pregnancy?
stop OC use as soon as a pregnancy is detected
| but teratogenic risk is prob low
211
when should you use a post-coital contraceptive?
when other means of contraception have failed
212
what is in post-coital contraceptives?
either high dose estrogen or high dose progestin or both
213
how effective are post-coital contraceptives?
99% in 1st 72 hours
214
define "infertility"
the inability to conceive after 1 year of unprotected intercourse
215
how many couples (%) are affected by infertility?
10-15%
216
most couples are considered to be (__?__) instead of infertile
subfertile
217
what is primary infertility?
no prior pregnancies
218
what is secondary infertility?
infertility following at least one prior conception
219
which is worse to have a baby: overweight or underweight
underweight
220
can you overcome assisted reproductive technologies if your pt smokes?
nope
221
what 3 lifestyle factors can cause infertility?
smoking
booze/caffeine
weight
222
what is your first question for infertile females?
are your menstrual periods regular or not
223
what is the pattern of menses of a woman who is most likely ovulating?
cyclic menses at an interval of 25-35 days w/ duration of bleeding 3-7 days
224
what is the best predictor of regular ovulation?
regular menstrual pattern
225
what are 4 tests you can use to assess ovulation?
1. basal body temp
2. sonography
3. ovulation prediction kit
4. midluteal serum progesterone levels
226
if you do sonography to assess ovulation, what do you look for?
follicle development
227
if you do a midluteal serum progesterone level, what level suggests ovulation?
~10 ng/mL or higher, 7 days after ovulation
228
abnormalities WHERE can perturb ovulation?
w/i the hypothalamus, ant pituitary, or ovaries
229
what are 2 types of inherited female anatomical disorders that can cause infertility?
1. distal outflow tract obstruction
| 2. mullerian defects
230
what are 3 types of distal outflow tract obstruction?
1. imperforate hymen
2. transverse vaginal septum
3. isolated vaginal atresia
231
what are 4 congenital uterine abnormalities?
1. uterine septum
2. bicornuate uterus
3. unicornuate uterus
4. uterine didelphys.
232
what birth defect is diethylstilbestrol linked to?
malformations of uterine development > small T shaped uterus
| plus inc risk for vaginal adenosis
233
what are 3 acquired uterine abnormalities?
1. intrauterine polyps
2. Leiomyomas
3. asherman syndrome
234
what are leiomyomas?
benign smooth muscle tumors
235
what is asherman syndrome?
intrauterine adhesions
236
what happens in hypergonadotropic hypogonadism?
loss of oocytes & the surrounding support cells before 40 yo
(dec or absent ovarian fxn)
(thus the hypogonadism)
237
what happens to FSH in hypergonadotropic hypogonadism?
they are HIGH
| thus the "hypergonadotropic
238
where is the primary dysfxn in hypergonadotropic hypogonadism?
ovary
239
what is another name for hypergonadotropic hypogonadism?
premature ovarian failure (POF)
240
what else, besides hypergonadotropic hypogonadism, can cause premature ovarian failure?
heavy smoking
ovarian surgery
chemo
pelvic irradiation
241
how can you predict that medical therapy will be of little benefit for a hypergonadotropic hypogonadism pt?
basal (day 2 or 3) FSH level above 15 IU/L
242
where is the primary abnormality in hypOgonadotropic hypogonadism?
hypothalamic-pituitary axis
243
what happens to FSH & LH in hypOgonadotropic hypogonadism?
low or even undetectable
244
is hypOgonadotropic hypogonadism inherited or acquired?
can be either
245
what is Kallmann syndrome?
a subset of pts w/ idiopathic hypOgonadotropic hypogonadism that have assoc ANOSMIA
246
what type of neurons are affected in hypOgonadotropic hypogonadism?
GnRH (?)
247
what is the mechanism in women that prevents pregnancy when resources are suboptimal?
hypothalamic amenorrhea or acquired hypothalamic dysfxn
248
what 5 things can bring on acquired hypothalamic dysfxn?
1. eating disorders
2. exercise induced
3. stress
4. hypothalamic tumors, trauma, radiation
5. pseudocyesis
249
what is Sheehan syndrome?
follows massive postpartum hemorrhage & assoc hypotension > leads to pituitary ischemia & necrosis
250
what is eugonadotropic amenorrhea?
chronic sex-steroid secretion interferes w/ normal feedback btwn the ovary & the hypothalamic-pituitary axis
251
what are 4 causes of eugonadotropic amenorrhea?
1. PCOS
2. adult-onset congenital adrenal hyperplasia
3. ovarian tumor
4. hyperprolactinemia & hypothyroidism
252
what causes adult-onset congenital adrenal hyperplasia?
21-hydroxylase gene mutation
| unable to convert enough P4 to cortisol so it all gets shunted to the androgen pathway
253
what does adult-onset congenital adrenal hyperplasia mimic?
PCOS
254
how can you correct hyperprolactinemia?
1. dopamine agonist
| 2. surgery if resistant
255
how can you treat hypothyroidism?
1. thyroxine
256
how do you induce ovulation in hyperprolactinemia or hypothyroidism?
clomiphene citrate
