Term
| 1. What are the potential adverse effects of the use of testosterone replacement? What labwork would you monitor? |
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Definition
Prolonged use of high doses: hepatitis and hepatic neoplasms
Otherwise: gynecomastia, decreased sperm levels
GU: urinary changes (hesitancy, nocturia-from increased prostate size), scrotal pain, groin pain.
Paradoxical decrease in libido, depression
Acne, baldness
Hyperlipidemia
GI: nausea, vomiting, edema, jaundice, cholestatic hepatitis
Women: menstrual irregularities, female virilization
After initiation of testosterone replacement draw free and total testosterone levels about 2-4 weeks after med start. |
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Term
| 2. What are the differences in the various birth control pills? |
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Definition
| There are two types of birth control pills: 1. combination pills which contain estrogen and progesterone and 2. progesterone only pills that only contain progesterone. The combination pills are broken down into three categories, monophasic, biphasic and triphasic. The monophasic pills contain estrogen and progesterone and the amounts do not vary throughout the cycle. In the biphasic pills, the estrogen remains unchanged and the progesterone level changes in the first and second week of the cycle. In triphasic pills, the estrogen and/or progesterone change during the cycle. The combination pills mainly contain ethinyl estradiol. The lower dose pills contain 35mcg or less. The high dose oral contraceptives contain 50mcg of estrogen. |
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Term
| 3. List the available progesterone agents. What is the difference between these and of what clinical importance is this to your patient? |
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Definition
The progesterones available in the oral contraceptives are as follows:
norethindrone, norethindrone acetate, levonorgestrel, norgestrel (marketed as Ovrette®-was removed from market in June of 2005)- these progesterones have high androgenic activity.
Ethynodiol diacetate, desogestrel, etonogestrel, norgestimate, drospirenone and norelgestromin-low androgenic activity.
Those progesterones that are more androgenic may have more side effects that are reasons that patients stop the contraception. The side effects of more androgenic progesterones include: increased hyperlipidemia, decreased glucose tolerance, increased acne, increased cardiovascular disease, hirsuitism, weight gain. |
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Term
| 4. If oral estrogen is given with an inducer of the P450 enzyme system, what may occur with the administration of both agents? |
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Definition
Specifically name those drugs that can cause this interaction.
If estrogens are given with an inducer, this decreases the plasma drug concentration of estrogen. In other words, the efficacy of the oral contraceptive or effect of the hormone therapy is lessened. For those patients that are taking these medications concurrently, the chance of pregnancy is higher. Some examples of inducers are Dilantin, carbamazepine, barbiturates. Also some antibiotics can decrease the effectiveness of the oral contraception (partially due to GI absorption also). |
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Term
| 5. What is the first sign of a drug interaction or decreased effect of birth control pills? |
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Definition
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Term
| 6. What are the most common adverse effects of Depo-Provera? |
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Definition
| Weight gain, mood swings, irregular bleeding, amenorrhea, reversibly decreases bone density. |
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Term
| 7. List the conditions in which estrogen therapy is contraindicated. |
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Definition
| Pregnancy, breast CA, endometrial CA, hepatic CA, cholestatic jaundice or history of jaundice with past pill use, thromboembolic disorders, undiagnosed vaginal bleeding, coronary artery disease, cerebrovascular disease. |
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Term
| 8. Consider some of the advantages and disadvantages of the various types of hormone therapy (including hormone replacement therapy). |
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Definition
Type Advantages Disadvantages
Hormone replacement therapy Treat vasomotor symptoms, treat urogenital symptoms, protection against osteoporosis Increased risk of problems associated with CAD, may increase risk of breast CA
Oral contraceptives Effective, return to fertility within few months, easy to discontinue if pregnancy desired, progesterone only pills can be used in breastfeeding mothers Easy to forget, may have increased side effects, drug interactions, does not protect against STD’s, combination pills cannot use in breastfeeding mothers
Patch Fewer side effects with dermal administration, easy to use, easy to discontinue if pregnancy desired or if discontinuation of HRT desired. May come off with sweating, birth control patch not as effective if patient is >198lbs. May have rash at site of application, no protection against STD’s, birth control patch cannot use in breastfeeding mothers
Vaginal rings Easy to use, rings in place for extended period of time, fewer side effects than oral administration, easy to discontinue. Patient has to be comfortable with inserting and removing, no protection against STD’s, birth control ring not used in breastfeeding mothers
Depo Provera Effective, given once every 3 months, can use in breastfeeding mothers Side effects not tolerated well in some, need to get IM injection, no protection against STD’s, return to fertility can take up to 18 months
IUD Effective for long length of time depending on which brand, return to fertility very quick, progesterone IUD’s may decrease menstrual bleeding Increased risk of infection, requires procedure to place, must be in monogamous relationship, only used in multiparous women |
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Term
| 9. What is the mechanism behind the disease osteoporosis? What are the diagnostic criteria? |
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Definition
| Osteoporosis is an imbalance between bone formation and bone resorption. The diagnostic criteria rely on the patients risk factors, family history and their DEXA scan results. The DEXA scan measures bone mineral density. It is measure in standard deviations from the norm (those of the same age and sex). If the results are >-1, the patient is within normal range, -1 to -2.5 is considered osteopenic, >-2.5 , the patient is considered to have osteoporosis. |
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Term
| 10. What is the mechanism of action of the bisphosphonates? |
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Definition
| The bisphosphonates inhibit bone resorption and increase bone density. They also inhibit osteoclast formation, decreasing their activity. The medication is deposited into the bone at the site of bone mineralization. |
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Term
| 11. What important instruction would you give your patient regarding the administration of the bisphosphonates? |
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Definition
| Because the bioavailability of the bisphosphonates is severely compromised with food intake, it is important to instruct your patient to take this med on an empty stomach and not eat for at least 30 minutes to one hour after taking this medication. |
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Term
| 12. How do the selective estrogen receptor modulators work and what are their clinical uses? What are the differences between the 2 available SERMs? |
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Definition
| They bind to estrogen receptors resulting in activation of certain estrogenic pathways and blockade of others. They have mixed antagonist and agonist effects on estrogen receptors in the body. Raloxifene has antagonist effects against estrogen receptors in breast and uterine tissue. It does stimulate estrogen receptors in bone reducing resorption of bone. It is clinically used in the treatment of osteoporosis. Its role in the treatment and prevention of breast cancer is still unclear. Tamoxifen has antagonist effects on estrogen receptors in breast tissue and bone but not in uterine tissue. This drug is specifically used in the prophylaxis of breast cancer in high risk patients and in the treatment of breast cancer. It does have agonist effects on uterine tissue therefore causing stimulation of uterine tissue. This in turn can cause a thickening of the uterine lining resulting in menstrual irregularities, uterine fibroids, hyperplasia etc. This is an adverse effect of this medication. |
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