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Estrogens and progestins are hormones with multiple actions.

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They promote female maturation and help regulate the ongoing activity of the female reproductive organs. In addition, they affect bone mineralization and lipid metabolism.

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Estradiol

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is the principal endogenous estrogen.

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Progesterone

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is the principal endogenous progestational hormone.

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The principal noncontraceptive application of estrogens and progestins

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menopausal hormone therapy (HT): Estrogens are given to manage hot flushes and other menopausal symptoms; progestins are given to oppose estrogen-mediated stimulation of the endometrium.

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The first half of the menstrual cycle (days 1 through 14) is called

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the follicular phase, and the second half is called the luteal phase. One full cycle typically takes 28 days.

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In the ovary, the following sequence occurs:

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(1) several ovarian follicles ripen; (2) one of the ripe follicles ruptures, causing ovulation; (3) the ruptured follicle evolves into a corpus luteum; and (4) if fertilization does not occur, the corpus luteum atrophies.

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In the uterus, these events occur:

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(1) while ovarian follicles ripen, the endometrium prepares for nidation by increasing in thickness and vascularity; (2) after ovulation, the uterus continues its preparation by increasing secretory activity; and (3) if nidation fails to occur, the thickened endometrium breaks down, causing menstruation, and the cycle begins anew.

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Two anterior pituitary hormones—follicle-stimulating hormone (FSH) and luteinizing hormone (LH)—

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play central roles in regulating the menstrual cycle.

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In premenopausal women, the ovary is

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the principal source of estrogen

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In the human male, small amounts of testosterone are

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converted into estradiol and estrone by the testes.

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Estrogens support

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the development and maintenance of the female reproductive tract and secondary sex characteristics.

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Estrogens can affect various nonreproductive tissues.

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Important among these are bone, blood vessels, and the heart, liver, and central nervous system (CNS).

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The principal concerns with estrogen therapy are

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the potential for endometrial hyperplasia, endometrial cancer, and cardiovascular events.

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Prolonged use of estrogens alone by postmenopausal women is associated

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with an increased risk of endometrial carcinoma. However, when estrogens are used in combination with a progestin, there is little or no risk of uterine cancer.

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Estrogen increases the risk of breast cancer primarily in

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postmenopausal women who are using estrogen combined with a progestin. Estrogen does not cause breast cancer--it only promotes the growth of a cancer that already exists, and then only if the cancer is estrogen receptor-positive.

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In postmenopausal women, therapy with estrogen alone or estrogen combined with a progestin may increase?

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the risk of ovarian cancer.

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In postmenopausal women, estrogen, used either alone or combined with a progestin, increases the risk of

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venous thromboembolism (VTE) and stroke

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In addition, estrogen alone increases

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the risk of coronary heart disease and myocardial infarction, but only in women older than 60 years.

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Nausea is the most frequent

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undesired response to the estrogens.

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Estrogens are classified by the U.S. Food and Drug Administration (FDA) as Pregnancy Risk Category

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X, not because they are especially harmful, but because they have no legitimate use in pregnancy

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Hormone therapy in postmenopausal women is

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the most common noncontraceptive use of estrogens.

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Causes of estrogen deficiency include

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primary ovarian failure, hypopituitarism, bilateral oophorectomy (removal of both ovaries), and Turner's syndrome (a genetic disorder that impairs gonadal function).

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In girls with estrogen insufficiency, puberty can be

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induced by giving exogenous estrogens.

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Estrogens, in the form of oral contraceptives, can help control

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acne

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SERMs

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drugs that activate estrogen receptors in some tissues and block them in others. These drugs were developed in an effort to provide the benefits of estrogen while avoiding its drawbacks.

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Three SERMs are available

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tamoxifen, toremifene, and raloxifene.

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Tamoxifen

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was the first SERM to be widely used. By blocking estrogen receptors, tamoxifen (and its active metabolite, endoxifen) can inhibit cell growth in the breast. As a result, the drug is used extensively to prevent and treat breast cancer.

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By activating estrogen receptors, tamoxifen protects against what?

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osteoporosis and has a favorable effect on serum lipids. However, receptor activation also increases the risk of endometrial cancer and thromboembolism.

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Raloxifene

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very similar to tamoxifen. The principal difference is that raloxifene does not activate estrogen receptors in the endometrium, and hence does not pose a risk of uterine cancer.

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Progesterone is produced by

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the ovaries and the placenta. Ovarian production occurs during the second half of the menstrual cycle.

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Progesterone secreted during

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the second half of the menstrual cycle converts the endometrium from a proliferative state into a secretory state. If implantation does not occur, progesterone production by the corpus luteum declines. The resultant fall in progesterone levels is the principal stimulus for the onset of menstruation.

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Progesterone levels increase during

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pregnancy. These high levels suppress contraction of uterine smooth muscle and thereby help sustain pregnancy.

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Unfortunately, progesterone also

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suppresses contraction of GI smooth muscle, which leads to prolonged transit time and constipation. In the breast, progesterone promotes growth and proliferation of alveolar tubules (acini), the structures that produce milk.

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High-dose therapy during the first 4 months of pregnancy has been associated with

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an increased incidence of birth defects.

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The primary noncontraceptive use of progestins is

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to counteract the adverse effects of estrogen on the endometrium in women undergoing HRT.

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Menopausal hormone therapy (HT) consists of low doses of estrogen (with or without a progestin) taken to compensate for

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the loss of estrogen that occurs during menopause.

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Menopause typically begins around age

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50 years, but can begin as early as age 48 and as late as age 55.

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loss of estrogen has multiple effects.

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Prominent among these are vasomotor symptoms, sleep disturbances, urogenital atrophy, bone loss, and altered lipid metabolism.

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The two basic regimens for HT are

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(1) estrogen alone and (2) estrogen plus a progestin.

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The purpose of estrogen in both regimens is to

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control menopausal symptoms by replacing estrogen that has been lost owing to menopause. The progestin is present for one reason only: to counterbalance estrogen-mediated stimulation of the endometrium, which can lead to endometrial hyperplasia and cancer.

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The benefits of long-term HT to prevent chronic disorders do not

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justify the risks.

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However, the use of short-term HT to manage menopausal symptoms

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is still deemed appropriate, provided women use the smallest effective dosage for the shortest time needed.

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The principal benefits of postmenopausal estrogen/progestin therapy (EPT) and estrogen therapy (ET) are

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suppression of menopausal symptoms and prevention of osteoporosis.

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Known risks of EPT include

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CHD, stroke, thromboembolic events, breast cancer, and dementia. ET appears to be safer than EPT but still can cause stroke, DVT, and other undesired effects.

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Vasomotor symptoms develop in

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about 70% of postmenopausal women. Hormone therapy is the most effective way to suppress symptoms.

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In the absence of estrogen, urogenital degeneration is inevitable. What can relieve these symptoms?

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Hormone therapy, either oral or topical, can reduce symptoms.

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Osteoporosis

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characterized by bone demineralization, altered bone architecture, and reduced bone strength.

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In the absence of estrogen, bone resorption accelerates, leading to a

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12% loss of bone density shortly after menopause.

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In menopausal women, HT can reduce

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bone resorption and slow the development of osteoporosis. More importantly, HT can decrease the risk of osteoporotic fractures.

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For all postmenopausal women, regardless of age, ET increases the risk of

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DVT and stroke. In addition, for women older than 60 years, ET increases the risk of MI and CHD.

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By contrast, for women age 50 to 59 years, ET appears to protect

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against MI and CHD.

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Estrogens increase the risk of

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endometrial hyperplasia and endometrial cancer, but only when used alone. When estrogens are combined with a progestin, the risk of endometrial cancer is reduced to the background level.

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Strong data show that HT using EPT increases both

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incidence of breast cancer and breast cancer mortality.

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Menopausal therapy with estrogen alone might increase

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breast cancer risk. If so, the risk for most women appears to be small, especially with short-term use.

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Menopausal HT appears to pose

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a small risk of ovarian cancer. However, data on this risk are conflicting.

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Postmenopausal EPT is associated with

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an increased risk of dying from non-small cell lung cancer (NSCLC), especially in current smokers.

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Postmenopausal ET and EPT increase

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the risk of cholecystitis.

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EPT increases

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he risk of dementia, primarily Alzheimer's disease.

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HT increases the risk of

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incontinence in women who are not incontinent and makes incontinence worse in women who already are.

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Should any woman use HT?

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The answer is "Yes"—provided the benefits for the individual outweigh the risks.

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For most women, the benefits of long-term HT for disease prevention do not

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outweigh the risks, and hence long-term HT should generally be avoided.

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Conversely, the benefits of short-term therapy (less than 4 to 6 years) to treat menopausal symptoms often

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do justify the risks.

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HT has only three approved indications:

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(1) treatment of moderate to severe vasomotor symptoms associated with menopause, (2) treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with menopause, and (3) prevention of postmenopausal osteoporosis.

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For women younger than 60 years who have undergone hysterectomy, HT may be

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safer than for any other group.

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Because the risks of HT are greater than previously appreciated, many women are

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discontinuing treatment.

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many women are discontinuing treatment. There are two basic methods:

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immediate cessation and tapering slowly. However, there are no controlled studies to indicate which option might result in fewer symptoms.

Chapter 61 Estrogen and Progestin – Flashcards

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