Hormones Flashcards
androgens
testosterone 1* male androgen. used to treat disorders in men and women. hypogonadims males. HIV, CA both sexes. androgens: testosterone (gel, transdermal), fluoxymesterone, methyltestosterone
androgen prescribing highlights (anabolic steroids)
scheduled drugs. contra: male breast or prostate CA. preg cat X, lactation. dont use transdermal in women.
androgen ADRs
liver (hepatitis, hepatic neoplasm, cholestatic hepatitis, jaundice, hepatocellular CA). women: virilization, menstraul irregularities. men: gynecomastia, reduced sperm, less libido (high levels), depression
androgen clinical use
male climacteric, primary hypogonadal males, hypogonadotropic hypogonadism. rational drug selection: IM vs PO vs transdermal vs newer nasal. aqueous vs oil IM preps.
androgen monitoring
serum T, lipids, liver fxn, CBC. men need PSA and digital prostate exam (increaed CA risk w/ lt therapy not as high as thought, unless already present). statins can decrease T on non clinically sig level
normal T range
250-110 ng/dL men, 2-45ng/dl women
estrogen products available
congugated equine estrogens (Premarin), esterified estrogen (estraidol, ethinyl estraidol), phytoestrogens
estrogen impact on body
bone density, normal skin and BV structure, increase serum triglycerides, improve HDL to LDL ratios, reduce bowel motility, enhance blood coag and fibrinolytic pathways, edema bc action on RAAS, maintain stability of thermoreg center
estrogen contras
estragen only contra in women with intact uterus. preg cat X, breast CA, estrogen-dependent neoplasm, active DVT/PE, past year stroke/MI, liver dysfunction, smokers
estrogen clinical use
contraception (combo estrogen, progest), releif peri and post menopause symptoms (Start on lowest dose, dont give unapposed dose to women w/uterus), vaginal atrophy and dryness (Cream, tabs, ring), osteoporosis
progesterones available
progesterone (Promethrium, Progesterone in Oil, Crinone, Procheive), medroxyprogesterone acetate (PRovera, Depo-PRovera), norethindrone/Aygestin, megestrol acetate/Megate
androgen derived progestins available
norethindrone, norethindrone acetate, ethynodial diacetate, norgestrol, desogestral, levonorogastrol, norestimate. dropserinone is a progestin dev from derivitive of spirolonactone
progesterones precautions and contraindications
depression, impaired liver function, breast CA, thromboembolitic disease, disorders that worsen with fluid retention, preg cat C for progesterone, preg cat X for norethindrone
progesterones ADRs
irreg bleed, amenhorea, acne,
injectible/implanted: weight gain, irreg menstrual bleed, osteoporosis
progesterones clinical use
post menopausal HRT when combo with estrogen when uterus intact. progestrin-only BC (norethindrone, DEpo-pRovera), progestin IUD Mirena
progesterones monitoring
depression, siezure increased risk if seizure disorder, DM monitorin BG
androgens in female puberty
skeletal growth spurt, pubic and axillary hair, sebacous gland activity, libido
effects of progestrin
thicken endometrium in prep for prego, thick cervical mucus and vag mucosa, relax smooth muscles of uterus and fallopian tubes; during prego maintain thick endometrium; reduced progestin leads to endometrial lining shed during period
menopausal changes
perimenopause cycles associated with elevated and irreg FSH, decreased inhibin, normal LH, slightly elevated estraoidol levels. menopause - no menses 12mos. vasomotor symptoms caused by estrogen level fluctiaonts. vaginal changes from low estrogen
goal of HRT in menopause
releif of symptoms assoc w menopause: prevent or lessen vasomotor symptoms, prevent or reduce vaginal atrophy, reduce risk osteo, ensure ben HRT outweigh risks
female menopause HRT contra and prec
not recc in cardiac disease. HRT may promote breast CA in older, not sure for younger. decreases risk of colon CA. osteo reduces risk but cant be prime reason to rx. inconsistent data on cog performance, sleep disturbance, skin change
starting and monitoring menopuase HRT
use lowest dose that releives symptoms for shortest time (up to 5y in menopause, longer with surgical menopause where ovaries removed). individualize drug choice and dose based on pt risk profile. monitor yearly
estrogen therapy
relief of perimenopause/postmenopause symptoms. start on lowest dose. no unopposed estrogen in those with intact uterus. symptoms start to imrpove 2 weeks, maximal effect 8 weeks. phytoestrogens and botanicals/herbals have inconstent results (red clover, soy, black cohosh, chaste tree fruit)
estrogen therapy for vulvovaginal atrophy and dryness
low dose 0.3-0.625mg/d improves symptoms. vaginal application can improve symptoms in 2 weeks ring or cream. topical application preferred d/t lower dose and no systemic effects
estrogen therapy risks
unopposed estrogen if intact uterus: endometrial CA. combo HRT: CHD risk, may be r/t onset and duration of therapy. increaed risk of stroke and thromboembolitic
progestin use
concraception or menorrhagea if alone. combo w/estrogen for post/peri menopausal women
combined estrogen/progestin therapy
mulitiple combos available. cyclical or sequential therapy is used if breakthrough bleeding a problem (estrogen is taken daily; medroxyprogesterone is taken for part of the cycle 10-12 d, 14d, or M-F). estrogen is started at low dose 0.3mg every other day for 2 mos then increase to daily for 2 mos before increasing dose
testosterone therapy in women
if menopause hot flashes dont improve with HRT/ERT, adding T may help. it must be combined with estrogen, or will cause masculinizing. acne is an issue
monitoring with HRT
yearly H&P, yearly pelvic exam, yearly mammogram, LFTs at baseline, lipid profile at baseline, >45 screen for DM2. abnormal uterine bleeding requires biopsy.
HRT outcome eval
successful treatment = symptom improvement. heavy menses 2gm drop in Hgb need referral to ru fibroids. any post menopuasal bleeding requires eval. urinary incontinence or chronic UTI requires eval.
osteoporosis
bone loss occurs when imbalance between osteoblast and osteoclast activity. increased fx risk. Dx: bone densitiy 2.5 SD below ave. the bone is histologically and biochemically normal.
bone impacts of estrogen
estrogen reduces bone resorbing action of PTH. PTH is released if serum calcium levels low and stimulates osteoclasts to resorb bone.
osteoporosis risk factors
fam hx, age >70, sight build, fair complexion, age, low Ca or Vit D diet, less sun exposure, weight <70kg, sedentary, l/t proton pump inhibitors, heavy tobacco or alcohol, anticonvulsants (phenobarbitol, phenytoin, carbamazepine), glucocorticoid use (>5mg/d >3mos), Asian (eat less Ca), AA have higher bone density but risk increases with age and they typically have low Ca intake
treatment of osteoporosis
vit D and Ca TOGETHER prevent/treat. bisphosphonates reduce bone resorption by inhibiting osteoclast activity. estrogen prevents bone resorption action of PTH. Selective estrogen receptor modulators (SERM) raloxifine/Evista has estrogenic effects on bone
goals of treatment for osteoporosis
Rx must be safe, affordable, effective. prevention best treatment: adequate Ca + vit D, low impact bone stressing exercise (not swim)
osteoporosis patient education
overall treatment plan: patho of disease, role of diet/caffeine/alc/smoke on risk of dev, importance of adquate ca/vit d regardless of treatment. admin of drug: drug interations, importance of being upright after biphosphonates
osteoporosis outcome eval
osteopenia begins 2-5 years after menopause if no HRT/ERT, no evidence on how fast/if pt will dev osteoporosis. consider referral for complex pts or dont respond to rx
DEXA screening is for
l/t estrogen deficient, vertebral abnormalities, to monitor osteoporosis treatment, l/t glucocorticoid or thyroid rx, with disease at risk for osteoporosis development, >40 with fracture, all women >65. additional considerations: smoker, BMI 20 or less, 127lb or less, surgical menopause <40, HRT for >10-15y, immobilitity >1y, premenopause with no bleed for >1y
osteoporosis monitoring
before treatment, r/o other disorders that may cause low bone density (hyperparathyroid, vit D deficiency, hyperthyroid, renal disease). measure bone mineral density, DEXA scan gold standard. 10% loss = double fx risk
biphosphonates vs estrogen
biphos no longer used for prevention. biphos first line for postmenopausal women and men >70 with osteoporosis. low dose estrogen maintains BMD.
osteoporosisi cost considerations
cost of biphosphonates approximately the same per month. Ibandronate is only once a month. estrogen and estrogen/progesterone less expensive but must be prescribed for other primary issue (menopause symptoms)
second line osteoporosis therapy
SERMS: Evista/reloxifene ; also protect against breast CA. Teriparatide (human PTH). reserved for highest risk patients who cant take biphosphonates (Cancer risk?). Denosumab very costly, only for highest risk patients
progesterone effects on body
increase body temp, increase insulin levels, may depress CNS
mechanism of prego prevention in BC
progestins primarily responsible for the contraceptive effect, they exhibit negative effect in hypothalamic-pituitary-ovarian axis. cause atrophy of endometrium, preventing implantation. estrogen part improves efficacy by suppressing FSH release, also provides cycle control
estrogen and progestin in BC
ethinyl estradiol (EE) or mestranol + gen 1-4 progesterones. 1st gen: norethindrone (acetate), ethynodial diacetate. 2nd gen: norgestrol, levonorgestrol. 3rd gen: desogestrel, norgestimate. 4th gen: drosperinone (spirolonactone derivative), 19-noresterone derivative dienogest
BC rational drug selection
start with absolute contras. delivery method of pt choice. fine tune based on bleeding pattern, SE profile. consider pts need for discretion, timing of subsequent prego. patient variables. all are similarly effective. cost : retail OC 30-70/cycle, generic OC some on $4 list, IUD upfront expense but lower overall
other benefits of BC
decreased dysmenorhea/irregular bleed/blood loss, acne, hirstuism, ovarian cysts, sig reduce endometrial and ovarian CA risk, lower risk benign breast conditions (eg fibrocystic changes and fibroadenoma), reduced risk of hospital for GC PID, supression of endrometriosis for women who dont currently desire prego
BC drug interactions and ADRs
TB drugs, antiepilieptics, St Johns WOrt. Lipide levels may be impacted by BC. ADRs: 3-5x higher risk thromboembolism for OC, cholestatic jaundice, benign hepatic neoplasms, MI, CVA, neurological migraines
BC dosing regimens
traditional (21 day active drug, 7d inactive with withdrawal bleed), extended (84d then 7d, so period every 3 mos). monophasic (same estrogen and progestin dose all cycle), biphasic (varied progestin dose), triphasic (vary dose of estrogen, progestin, or both)
BC starting methods
first day start (start 1st day period, no backup). Sunday start (first pill SUnday after period starts, backup first 7d, only have period during week), quick/same day start (first pill day of office visit, backup first 7 days)
Ortho Evra topical patch
20mcg EE and 150mcg norelgestromin. applied weekly for 3weeks, then week off. start first day period, or other day if backup used. ADRs similar to OC. Weigh >198lb increaesd failure rate.
Nuvaring
15mcg EE and 120mcg etongestrel daily. 3 weeks on 1 week off. better cycle control, less breakthrough bleed than OC. lower systemic exposure to EE
progestin only BC pills
used when estrogen contra. effect through thick cervical mucus and prevention of sperm penetration. have to be diligent taking dose same time daily, if even a few hours late , backup needed for next 48h. common ADR: breast tender, changing bleed patterns
Depo Provera (depot medroxyprogesterone acetate)
long acting progestin only injcatable contraception. one injection - 12-13wk ovulation supression, effective. disadvantages: weight gain, depression, spotting then amenhorea, black box: decreased bone density l/t use
intrauterine progestin (Mirena IUD)
20mcg levonorgestrol daily. left up to 5y. only small level cirulating hormone, minimal SE systemically. changes in menstrual bleed, amenhorrea
Implanon implantable progestin
rod contains 68mg etonogestrel, up to 3y
emergency contraception
soon as possible <72h after unprotected sex, but can be up to 120hr. methods: combined OCs, Progestin only (Plan B, Next Choice), copper IUD
BC monitoring
routine female screening (history, breast and pelvic exam, PAP and STI, BP). specific to contraception: history, BP. The others are not required to give rx. Monitor BP and ADRs at 3mos then yearly
