Exam 4- Women's Health Flashcards
What hormone is released from the hypothalamus to help regulate the menstrual cycle?
gonadotropin releasing hormone
When does gonadotropin releasing hormone reach it’s peak?
right before ovulation
What are the two gonadotropic hormones that regulate the menstrual cycle?
FSH and LH
When do FSH and LH peak?
ovulation ( ~ day 14)
What are the ovarian hormones?
progesterone and estrogen
When does estrogen peak?
Ovulation
When does progesterone peak?
in the luteal phase- it’s function is to maintain the endometrium
Where are FSH and LH released from?
the anterior pituitary
In which phase of the menstrual cycle is the release of estrogen stimulated?
the follicular phase
In which phase of the menstrual cycle is the release of progesterone stimulated?
the luteal phase
What function does estrogen play in the HPO axis?
estrogen stimulates GnRH secretion and produces the LH surge
What function does inhibin play in the HPO axis?
inhibin inhibits the secretion of FSh
What function does progesterone play in the HPO axis?
negative feedback for GnRH
What is the effect of estrogen during puberty?
stimulate breast development, fat deposition, and increase growth hormone and height.
What is the effect of estrogen throughout the reproductive years?
maintain female sexual physical characteristics, behaviors, and reproductive organs. Stimulate cyclic uterine lining growth and repair.
contraindications to estrogens
- abnormal vaginal bleeding
- DVT or PE (blood clots)
- active or history of stroke or heart attack
- breast cancer
- hypercoagulable disorder
- pregnancy
estrogen uses
- breast cancer palliation
- uremic bleeding
- prevention of post-menopausal osteoporosis
- vasomotor symptoms of menopause
- vulvar and vaginal atrophy
- female hypogonadism
- ovarian failure
- abnormal uterine bleeding
- contraception
what is progesterone produced by?
ovary and corpus luteum
what is the target of progesterone?
uterus
what is the target of estrogen
many systemic targets
what is the role of progesterone in pregnancy?
- prepare endometrium for pregnancy
- inhibits contraction of the uterus
- inhibits development of a new follicle
- maintaining the endometrial lining
what are the available forms of medroxyprogesterone?
Depo-Provera (injection) and Provera (tablet)
What are contraindications of medroxyprogesterone?
- history or current VTE
- severe hepatic dysfunction
- breast cancer
- undiagnosed vaginal bleeding
- use for more than 2 years: may result in loss of bone mineral density
What is the role of medroxyprogesterone?
- reduce risk of endometrial cancer with unopposed estrogen treatment
What are the therapeutic uses of progestins?
- long-term pregnancy prevention
- treatment of heavy menstrual bleeding
- emergency contraception
- amenorrhea
- endometriosis
What drugs are GnRH agonists?
Leuprolide, buserelin, nafarelin, goserelin, triptorelin
What is the mechanism for GnRH agonists?
Creating a pseudomenopausal state
What are side effects of GnRH agonists?
hot flashes, vaginal dryness, insomnia, osteoporosis
What are the therapeutic uses of GnRH agonists?
Menorrhagia, endometriosis, and premenstrual dysphoric disorder
What is menopause?
- marks the end of fertility
- inability of ovaries to produce estrogen
- diagnosis is confirmed after 12 consecutive months of amenorrhea
What is premenopause?
- The time period of endocrine changes before cessation of menstruation
- most symptoms occur during this period
What is perimenopause?
the period of endocrine changes surrounding menopause, marked by irregular periods.
What is postmenopause?
the time period of endocrine changes after cessation of menstruation
When is menopause most likely?
Median age of onset is 51 years
What is premature menopause?
- occurs before age 40
- normally due to hysterectomy, radiation therapy, or chemotherapy
- increased risk of mortality and morbidity
- worst symptoms first 1-2 years due to estrogen deficiency
What are the causes of menopause?
- physiologic (deterioration of follicular cells and ova with aging. Decreased estrogen and progesterone levels and increased FSH and LH levels)
- surgery- removal of ovaries or full hysterectomy
- chemotherapy
- radiation therapy
What are vasomotor symptoms of menopause?
Hot flashes and night sweats
What happens to vasomotor symptoms over time?
they get better long-term and become less severe
What are genitourinary symptoms of menopause?
irregular menses, amenorrhea, sleep disturbances, mood changes, fatigue, vulvovaginal atrophy, urinary tract dysfunction, sexual dysfunction, urinary frequency and urgency
What are long-term consequences of menopause?
cardiovascular disease, bone loss, osteoarthritis, body composition changes, skin changes, balance issues
What are the options for treatment of menopausal symptoms?
nonpharmacologic therapy, menopausal hormone therapy, and nonhormonal alternatives
What are nonpharmacologic therapies for treatment of menopause symptoms?
- smoking cessation
- limit alcohol and caffeine use
- limit hot beverages
- limit spicy foods
- weight loss
- keep cool; dress in layers
- others
what are indications for menopausal hormone therapy?
vasomotor symptoms, vulvovaginal atrophy, osteoporosis prevention
absolute contraindications to MHT
- unexplained vaginal bleeding
- pregnancy
- endometrial or breast cancer
- stroke
- active or history of thromboembolic disorders
- active liver disease
relative contraindications to MHT (needs monitored)
- uterine leiomyoma
- migraine headaches
- seizure disorders
- diabetes
- hypertriglyceridemia
- active gallbladder disease
- high risk for heart disease
- family history of breast cancer
When can estrogen monotherapy be used?
When a woman does not have a uterus
What is the risk of estrogen monotherapy in women with a uterus?
risk for endometrial cancer/hyperplasia
Oral estrogen monotherapy options
- premarin (conjugated estrogens)
- menest (esterifies estrogen)
- estrace generics (micronized estradiol)
What are side effects or key points of oral estrogen products?
- undergo hepatic first-pass metabolism
- systemic effects –> more side effects
- effective for hot flashes
Transdermal estrogen monotherapy options
- alora
- climara
- menostar
- minivelle
- vivelle
- vivelle-dot
Key points for transdermal estrogen therapy
- continuous rate of hormone release
- less side effects and risk of stroke
topical estrogen therapy products
- topical gels
- topical sprays
topical estrogen therapy key points
- variable absorption
IM injections for estrogen therapy products
- estradiol cypionate (depo-estradiol)
- estradiol valerate (delestrogen)
Intravaginal estrogen products
Vaginal cream (estrace; premarin)
Vaginal insert (Imvexxy)
Vaginal tablet (vagifem, yuvafem)
Vaginal ring (estring, femring)
intravaginal estrogen product key notes
- are put on a localized area = minimal systemic absorption
- patient can use even if they have an intact uterus
- femring has systemic absorption; can help with vasomotor symptoms but a progesterone is needed
When should topical vaginal products be prescribed?
exclusively for women experiencing vulvovaginal atrophy
When should progestin be used
in women with an intact uterus in addition to estrogen to decrease the risk of endometrial hyperplasia and endometrial cancer.
When should MHT be started?
- ideally in women under age 60, within 10 years of menopause
- lowest risk of coronary heart disease
what is continuous cyclic therapy?
- estrogen is administered daily and progesterone is administered 12 to 14 days of a 28 day cycle.
- mimics the menstrual cycle
- includes scheduled withdrawal bleeding
- preferred in perimenopausal women and recently menopausal women
continuous cyclic therapy drug options
premphase (oral)- conjugated estrogens and medroxyprogesterone acetate
combipatch (transdermal)- estradiol and norethindrone acetate
What is continuous long cycle hormone therapy?
- estrogen administered daily
- progesterone co-administered 12 to 14 days every other month
- 6 scheduled bleeds (longer and heavier withdrawal bleeds)
- not as much endometrial protection
- not used as often
What is continuous combined hormone therapy?
- daily estrogen and progesterone
- endometrial atrophy and absence of vaginal bleeding
- initial unpredictable spotting or bleeding (should resolve within 6-12 months)
- drug free period of 1-2 weeks may help stop bleeding
- recommended for women >2 years post menopause
- best long-term endometrial protection
continuous combined hormone therapy options
- many different oral options
- climapro and combipatch are transdermal options
-climapro is preferred due to low risk of side effects.
what is intermittent combined hormone therapy?
- continuous pulsed estrogen and progesterone
- 3 days of estrogen + progesterone
- pulsing prevents bleeding
- long-term endometrial protection is unknown
What is the best oral progestin for endometrial protection?
- micronized progestin (prometrium)
- no increased cardiovascular risk; closest to biological progesterone
What can combination therapy of estrogen and SERMs be used for?
treats menopausal symptoms and prevents bone loss in women with an intact uterus
- decreases risk of endometrial cancer (antagonist to breast and uterus)
- higher risk of hyperplasia and stroke in overweight women
What is the most commonly used estrogen/SERM therapy
Duavee
Estrogen + SERM side effects
GI track disorders, muscle spasms, neck pain, dizziness, oropharyngeal pain
What are alternatives for vasomotor symptoms?
- phytoestrogens, black cohosh, dong quai, gabapentin/pregabalin, and clonidine
When are SSRIs and SNRIs used for hot flashes?
Drug of choice if estrogen treatment is contraindicated
What are the drugs of choice and key points for use of SSRIs?
Paroxetine, citalopram, and escitalopram
- help with vasomotor symptoms and mood
What are the drugs if choice and key points for use of SNRIs to treat post-menopausal symptoms
venlafaxine, desvenlafaxine, duloxetine
- should not stop abruptly (need to taper)
- side effects: mouth dryness, anorexia, nausea, constipation
What is bioidentical hormone replacement therapy?
- compounds with a unique mix of estradiol, estrone, estriol, and progestone
- not usually covered by insurance
- only FDA approved is Bijuva
- questionable safety, efficacy, and potency
what is the first-line treatment for genitourinary symptoms of menopause?
- non-hormonal lubricants and vaginal moisturizers
What is the second-line treatment for genitourinary symptoms of menopause?
- estrogen topical creams, tablets, and rings
- low dose oral contraceptives
- low dose vaginal estrogen does not require progestin
What medication is used for the treatment of moderate to severe dyspareunia?
ospemifene
What is ospemifene?
- SERM
- black box warning for endometrial cancer, stroke, and VTE
- used in post-menopausal women for painful sexual intercourse
- may cause hot flashes
What is prasterone (intrarosa)? Indication, side effects, etc.
- inactive DHEA converted to active estrogens and androgens
- intravaginal inserts; used for post-menopausal women only
- only contraindication is undiagnosed vaginal bleeding and avoid if history of breast cancer
What are the two main thyroid hormones?
Thyroxine (T4) and triiodothyronine (T3)
- T4: concentration is 10x higher than T3; converted to T3 by enzymes
- T3: most potent
What are the physiologic effects of thyroid hormones?
Growth and development (absent T3= cretinism), metabolic effects (increases BMR and oxygen consumption; starvation lowers T3 hormone and thyroid receptor), thermogenesis (increase resting heat production), cardiovascular effects including catecholamine sensitivity (epinephrine/norepinephrine)
How are thyroid hormones synthesized?
using dietary iodine (I2)
What catalyzes iodide organification?
- thyroid peroxidases
What hormone is released from the hypothalamus to control thyroid hormone synthesis?
TRH (thyrotropin releasing hormone)
What hormone is released from the anterior pituitary to control thyroid hormone synthesis?
TSH (thyrotropin)
What is released from the thyroid gland?
T4 and T3
What stimulates production of T4 and T3 from the thyroid gland?
thyrotropin (released by the anterior pituitary)
What is iodine used for?
- used in synthesis of thyroid hormones
What does iodine deficiency cause?
- nontoxic goiter
- enlargement of the thyroid gland due to rise in TSH but lack of T4
How are thyroid hormones transported in the body?
- transported in plasma by thyroxine-binding globulin
- transport proteins have greatest affinity to T4
- T4 has a longer-half life than T3; but T3 has a more rapid onset due to less binding affinity
how is T3 made?
T4 converted to T3 by deiodinase
What are symptoms of hypothyroidism
decrease in metabolic rate (fatigue, lethargy, attention deficit)
- defective thermoregulation (cold)
- may occur with thyroid enlargement (non-toxic goiter)
- causes dwarfism and cretinism in children
- myxoedema coma if left untreated (water intoication, shock, and death)
what are causes of hypothyroidism
hashimotos thyroiditis- an autoimmune disease that destroys the thyroid gland
- secondary causes include TSH deficiency
hyperthyroidism symptoms
- excessive metabolism
- poor thermoregulation (hot)
- weight loss
- increased heart rate and cardiac output
Hyperthyroidism causes
grave’s disease- an autoimmune disease; thyroid-stimulating antibodies (enlargement of the thyroid gland– toxic goiter)
- thyroiditis– infection; release of thyroid hormones
What are characteristics of a toxic goiter
excess T3
What is hyperglycemia caused by?
hyperthyroidism
What is hypoglycemia caused by?
hypothyroidism
thyroid hormone replacement therapy
levothyroxine (t4)
levothyronine (t3)
