Common Estrogens and Estrogen/Progestin Combinations Quiz
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Questions and Answers

What is the primary source of estrogen in premenopausal women?

  • Placenta
  • Corpus luteum
  • Ovaries (correct)
  • Endometrium

    • What triggers the LH surge at midcycle in females?

  • Estrogen suppression
  • Rise in FSH levels (correct)
  • Progesterone secretion
  • Thickening of the endometrium

    • What is the main effect of estrogens on bone health?

  • Blockage of bone resorption (correct)
  • Promotion of bone resorption
  • Decrease in mineral deposition in bone
  • Activation of vasoconstriction

    • How do endogenous estrogens affect glucose homeostasis?

    <p>Improve glucose tolerance</p> Signup and view all the answers

    What is the role of estrogens during the first half of the menstrual cycle?

    <p>Cause proliferation of the endometrium</p> Signup and view all the answers

    What happens to the corpus luteum at the end of the menstrual cycle?

    <p>It atrophies</p> Signup and view all the answers

    During which phase of the menstrual cycle are estrogens and progesterone mainly produced by the corpus luteum?

    <p>Second half</p> Signup and view all the answers

    What is the consequence of a diminished supply of ovarian hormones at the end of the cycle?

    <p>Endometrial breakdown</p> Signup and view all the answers

    Which event follows ovulation in the sequence of ovarian events?

    <p>Ruptured follicle evolves into a corpus luteum</p> Signup and view all the answers

    Which of the following is NOT a physiological alteration associated with estrogen?

    <p>Enhanced long-term memory</p> Signup and view all the answers

    What is a major consideration when prescribing estrogens to patients?

    <p>History of liver disease</p> Signup and view all the answers

    Which of the following formulations of estradiol offers the advantage of bypassing the liver?

    <p>Emulsion</p> Signup and view all the answers

    What is a characteristic of phytoestrogens?

    <p>Plant-based compounds</p> Signup and view all the answers

    In what scenario would intravenous administration of estrogens be used?

    <p>Emergency control of heavy uterine bleeding</p> Signup and view all the answers

    What is the primary estrogen used for transdermal therapy?

    <p>Estradiol</p> Signup and view all the answers

    What is the disadvantage of giving progestin cyclically along with continuous estrogen therapy?

    <p>Promotion of monthly bleeding</p> Signup and view all the answers

    Which medication is commonly used to decrease testosterone levels in transgender women?

    <p>Spironolactone</p> Signup and view all the answers

    What remains the greatest risk factor associated with estrogen therapy for both transgender and nontransgender patients?

    <p>Thromboembolic events</p> Signup and view all the answers

    What drug was approved by the US Food and Drug Administration in 2015 for managing Female Sexual Interest/Arousal Disorder (FSIAD)?

    <p>Sildenafil</p> Signup and view all the answers

    What is the only approved indication for long-term progestin therapy alongside estrogen therapy?

    <p>Protection against endometrial cancer</p> Signup and view all the answers

    Why is the use of estrogen and progestin therapy (EPT) limited to women with an intact uterus?

    <p>To protect against endometrial cancer</p> Signup and view all the answers

    Which treatment is recommended by the FDA for managing vulvar and vaginal symptoms caused by menopause?

    <p>Topical estrogen formulation</p> Signup and view all the answers

    Why are alternative treatments preferred over hormone therapy for postmenopausal osteoporosis prevention?

    <p>To maintain bone health after discontinuation</p> Signup and view all the answers

    Which drug, commonly used for vasomotor symptoms in menopause, was approved in 2013 but has since fallen out of favor?

    <p>Paroxetine</p> Signup and view all the answers

    What is the primary mechanism by which combination OCs reduce fertility?

    <p>Suppressing follicular maturation</p> Signup and view all the answers

    Which drug is administered by subcutaneous injection at least 45 minutes before sexual activity occurs?

    <p>Bremelanotide (Vyleesi)</p> Signup and view all the answers

    Which contraceptive method should be avoided by women with certain cardiovascular disorders as well as women older than 35 years who smoke?

    <p>Combination oral contraceptives (OCs)</p> Signup and view all the answers

    Which common side effect is associated with the drug Flibanserin (Addyi)?

    <p>Hypotension with or without syncopy</p> Signup and view all the answers

    What is the most recent drug approved for low libido not associated with medical or mental health problems in women?

    <p>Bremelanotide (Vyleesi)</p> Signup and view all the answers

    Why does ovarian progesterone production decline after 10 weeks of gestation?

    <p>As a result of sufficient progesterone production by the placenta</p> Signup and view all the answers

    What is the primary purpose of progestins in hormone therapy (HT)?

    <p>To counterbalance estrogen-mediated stimulation of the endometrium</p> Signup and view all the answers

    Which progestin is used specifically to support early pregnancy in women undergoing IVF?

    <p>Micronized progesterone</p> Signup and view all the answers

    Why was hormone therapy (HT) prescribed liberally until the Women’s Health Initiative Study results were published?

    <p>To alleviate vasomotor symptoms in postmenopausal women</p> Signup and view all the answers

    What impact did the Women’s Health Initiative Study have on hormone therapy (HT) recommendations?

    <p>It led to a reevaluation and recommendation of using the lowest effective dose for the shortest period in specific age groups</p> Signup and view all the answers

    Which phytoestrogen is commonly derived from plants such as soy beans and red clover?

    <p>Isoflavones</p> Signup and view all the answers

    What is a common misconception about phytoestrogen therapy based on the text?

    <p>Randomized controlled trials consistently support its use</p> Signup and view all the answers

    How do selective estrogen receptor modulators (SERMs) differ from estrogen according to the text?

    <p>SERMs activate estrogen receptors in some tissues and block them in others</p> Signup and view all the answers

    Why is raloxifene different from tamoxifen, according to the text?

    <p>Raloxifene does not activate estrogen receptors in the endometrium, unlike tamoxifen</p> Signup and view all the answers

    During which weeks of gestation does the placenta start sharing the production of progesterone with the corpus luteum?

    <p>Weeks 7-10</p> Signup and view all the answers

    Why is it important to take progestin-only pills (minipills) at the same time every day?

    <p>To ensure contraceptive effectiveness</p> Signup and view all the answers

    What is the main drawback associated with progestin-only pills (minipills) compared to combination OCs?

    <p>Irregular bleeding</p> Signup and view all the answers

    What is the recommended action if one or two pills are missed during the second or third week of a 28-day cycle of combination OCs?

    <p>Skip the placebo pills and go straight to a new pack</p> Signup and view all the answers

    Why might health care providers recommend taking combination OCs for an extended time rather than following the traditional 28-day cycle?

    <p>To reduce episodes of withdrawal bleeding</p> Signup and view all the answers

    What should be done if three or more pills are missed during the second or third week of a 28-day cycle of combination OCs?

    <p>Use an additional form of contraception for 7 days</p> Signup and view all the answers

    Why is it recommended to commence successive dosing cycles of combination OCs every 28 days?

    <p>To suppress endometrial thickening</p> Signup and view all the answers

    What is the recommended backup contraceptive method if two pills of progestin-only OCs are missed?

    <p>Restart the regimen and use condoms for at least 2 days</p> Signup and view all the answers

    What distinguishes the dosing schedule of the transdermal contraceptive patch from combination OCs?

    <p>The patch is administered once a week</p> Signup and view all the answers

    What common adverse effect is associated with the use of NuvaRing?

    <p>Vaginitis</p> Signup and view all the answers

    What is the unique component in Natazia that sets it apart from other combination oral contraceptives?

    <p>Dienogest</p> Signup and view all the answers

    What is the mechanism of action of Nexplanon in preventing pregnancy?

    <p>A combination of inhibiting ovulation, thickening cervical mucus, and thinning endometrium</p> Signup and view all the answers

    How do monophasic, biphasic, triphasic, and quadriphasic oral contraceptive regimens differ from each other?

    <p>By altering both estrogen and progestin doses throughout the cycle</p> Signup and view all the answers

    What is a characteristic of Depot medroxyprogesterone acetate's (DMPA) contraceptive effect?

    <p>Inhibits follicular maturation and ovulation</p> Signup and view all the answers

    How do oral contraceptives interact with drugs that induce hepatic cytochrome P3A4?

    <p>They accelerate the metabolism of oral contraceptives</p> Signup and view all the answers

    What is a common reason for discontinuation of Nexplanon use?

    <p>Irregular and unpredictable bleeding</p> Signup and view all the answers

    What effect do oral contraceptives have on glucose levels in diabetic patients using hypoglycemic agents?

    <p>Counteract the benefits of hypoglycemic agents</p> Signup and view all the answers

    How do combination oral contraceptives affect the menstrual flow in women who use them?

    <p>Reduce menstrual flow volume</p> Signup and view all the answers

    What is a potential consequence of combining warfarin with oral contraceptives?

    <p>Reduced effectiveness of warfarin</p> Signup and view all the answers

    What is the main indication for long-term progestin therapy alongside estrogen therapy?

    <p>Reducing the risk of endometrial hyperplasia</p> Signup and view all the answers

    What is the primary mechanism by which combination OCs reduce fertility?

    <p>Inhibition of ovulation</p> Signup and view all the answers

    Why is raloxifene different from tamoxifen, according to the text?

    <p>Tamoxifen is associated with a lower risk of endometrial cancer</p> Signup and view all the answers

    Which contraceptive method should be avoided by women with certain cardiovascular disorders as well as women older than 35 years who smoke?

    <p>Combined oral contraceptives (COCs)</p> Signup and view all the answers

    Why are alternative treatments preferred over hormone therapy for postmenopausal osteoporosis prevention?

    <p>Hormone therapy has a higher risk of breast cancer</p> Signup and view all the answers

    What is a common misconception about phytoestrogen therapy based on the text?

    <p>Phytoestrogens can be used indefinitely without side effects</p> Signup and view all the answers

    Which of the following estrogens undergoes conversion to ethinyl estradiol in the body?

    <p>Mestranol</p> Signup and view all the answers

    What is the main reason for the reduced efficacy of oral contraceptives in women with higher weight?

    <p>Sequestration of hormones in adipose tissue</p> Signup and view all the answers

    Which of the following is NOT a factor that influences the efficacy of oral contraceptives?

    <p>Age of the woman</p> Signup and view all the answers

    What is the failure rate of oral contraceptives with typical use?

    <p>8%</p> Signup and view all the answers

    Which generation of progestins in combination oral contraceptives exhibits thrombotic events as a significant side effect?

    <p>Third generation</p> Signup and view all the answers

    Why are combination oral contraceptives considered more reliable than most alternatives despite their side effects?

    <p>Comparable effectiveness with reduced mortality</p> Signup and view all the answers

    How soon after unprotected intercourse must a woman take a second tablet of levonorgestrel based on the package insert?

    <p>12 hours later</p> Signup and view all the answers

    In what situation would mifepristone be considered an abortifacient?

    <p>Taken more than 5 days after unprotected intercourse</p> Signup and view all the answers

    Which drug requires a prescription for all women regardless of age?

    <p>Mifepristone (RU 486)</p> Signup and view all the answers

    What is the dosage for ulipristal acetate to be taken up to 5 days after unprotected intercourse?

    <p>1 tablet (30 mg)</p> Signup and view all the answers

    What is the primary mechanism through which ulipristal acetate prevents conception?

    <p>Suppressing ovulation</p> Signup and view all the answers

    Which condition is a major contraindication to the use of mifepristone/misoprostol?

    <p>Hemorrhagic disorders</p> Signup and view all the answers

    What is the primary action of mifepristone in preventing pregnancy?

    <p>Blocking progesterone receptors</p> Signup and view all the answers

    Which side effect is NOT commonly associated with the use of mifepristone?

    <p>Blurred vision</p> Signup and view all the answers

    "Cotreatment with misoprostol is usually required" for which medication?

    <p>&quot;Mifepristone (RU 486)&quot;</p> Signup and view all the answers

    Study Notes

    Estrogens and Progesterones

    • Estrogens and progesterone are produced by the ovaries and play a crucial role in the menstrual cycle
    • During the first half of the cycle, estrogens are secreted by maturing ovarian follicles, causing proliferation of the endometrium
    • At midcycle, one of the ovarian follicles ruptures, forming a corpus luteum, which produces estrogens and progesterone
    • The corpus luteum maintains the endometrium in a hypertrophied state until the end of the cycle
    • Decreased production of ovarian hormones leads to breakdown of the endometrium and menstruation

    Regulation of the Menstrual Cycle

    • Two anterior pituitary hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), regulate the menstrual cycle
    • FSH acts on developing ovarian follicles, causing them to mature and secrete estrogens
    • LH surge at midcycle causes the dominant follicle to rupture, releasing an ovum
    • LH also stimulates the corpus luteum to produce progesterone

    Estrogens

    • Estrogens are produced by the ovaries and are responsible for the growth and maturation of the female reproductive tract
    • Estrogens also direct pigmentation of the nipples and genitalia
    • During the follicular phase, estrogens promote ductal growth in the breast, thickening of the vaginal epithelium, and proliferation of the uterine epithelium
    • Estrogens also increase vaginal acidity and stimulate uterine blood flow and growth

    Physiologic Effects of Estrogens

    • Estrogens have a positive effect on bone by blocking bone resorption and promoting mineral deposition
    • Estrogens lower cardiovascular risk by decreasing vasoconstriction and raising HDL
    • Estrogens promote blood coagulation and have a neuroprotective effect
    • Estrogens preserve cognitive function, enhance short-term memory, and regulate mood

    Therapeutic Uses of Estrogens

    • Estrogens are used for menopausal hormone therapy (HT), female hypogonadism, and acne
    • Estrogens are also used for cancer palliation and gender affirmation therapy for transgender women

    Adverse Effects of Estrogens

    • Estrogens can cause endometrial hyperplasia, endometrial cancer, breast cancer, and cardiovascular thromboembolic events
    • Estrogens are contraindicated in patients with a history of deep vein thrombosis, pulmonary embolus, or liver disease

    Progesterone

    • Progesterone is produced by the ovaries and placenta
    • Progesterone is synthesized by the corpus luteum in response to LH
    • Progesterone production by the corpus luteum ceases if implantation of a fertilized ovum does not occur

    Therapeutic Uses of Progesterone

    • Progesterone is used for HT, dysfunctional uterine bleeding, amenorrhea, and endometrial hyperplasia and carcinoma
    • Progesterone is also used to support early pregnancy in women undergoing IVF and to prevent preterm birth

    Adverse Effects of Progesterone

    • Progesterone can cause breast tenderness, headache, abdominal discomfort, arthralgias, and depression

    Hormone Therapy (HT)

    • HT consists of low doses of estrogen (with or without a progestin) taken to compensate for the loss of estrogen during menopause

    • HT is used to control menopausal symptoms, including vasomotor symptoms, sleep disturbances, and improved cognition and mood

    • The risks of HT, including breast cancer and thromboembolic events, must be weighed against its benefits### Hormone Therapy (HT) for Menopause

    • HT has three approved indications: treatment of vasomotor symptoms, genitourinary syndrome, and prevention of postmenopausal osteoporosis.

    • Duration of treatment is relatively short for vasomotor symptoms and genitourinary syndrome (typically 3 to 4 years), but lifelong for prevention of osteoporosis.

    • HT is the most effective treatment for vasomotor symptoms, and the lowest effective dosage should be used to increase safety.

    Alternatives to HT

    • Two antidepressants, escitalopram and desvenlafaxine, can reduce hot flashes.
    • Other options, such as clonidine and pregabalin, have also shown some success.
    • Soy isoflavones and black cohosh are not effective in reducing hot flashes.

    Genitourinary Syndrome of Menopause

    • HT is the most effective treatment for genitourinary syndrome, characterized by dryness, irritation, and uncomfortable intercourse.
    • Topical estrogen formulations, such as vaginal creams and rings, are safer than oral estrogen and can be used to manage vulvar and vaginal symptoms.

    Postmenopausal Osteoporosis

    • HT reduces bone loss and decreases the risk of osteoporosis and related fractures.
    • However, when HT is stopped, bone mass rapidly decreases, and alternative treatments are preferred.

    Inappropriate Uses of HT

    • HT is not recommended for cardiovascular disease or dementia.
    • Discontinuation of HT may cause vasomotor symptoms to return, and no firm guidelines exist for stopping HT.

    Estrogen and Progestin Therapy

    • Estrogen and progestin are commonly administered continuously, but an alternative is to give estrogen continuously and give progestin cyclically.
    • Vaginal estrogens can be given continuously for 1 to 2 weeks, followed by dosing 1 to 3 times per week.

    Transgender Hormonal Therapy

    • Transgender women require medication to decrease testosterone levels and estrogen to promote female characteristics.
    • Management is highly individualized, and monitoring of therapy must include the effects of estrogen and antiandrogens.
    • Risks of HT are the same as for nontransgender patients.

    Female Sexual Interest/Arousal Disorder (FSIAD)

    • FSIAD is a common problem in women, especially after menopause.
    • Treatment options include off-label use of drugs such as sildenafil and testosterone, and newly approved drugs such as flibanserin and bremelanotide.

    Birth Control

    • Several factors should be considered when choosing a method of birth control, including effectiveness, safety, and personal preference.
    • The most effective methods are etonogestrel subdermal implants, intramuscular medroxyprogesterone acetate, sterilization, and IUDs.
    • Combination oral contraceptives (OCs) are effective, but their effectiveness is impacted by factors such as weight and smoking.

    Contraceptive Methods

    • OCs reduce fertility primarily by inhibiting ovulation.
    • Combination OCs employ three estrogens: ethinyl estradiol, mestranol, and estradiol valerate.
    • Progestins in OCs can be grouped into four generations, with differences in side effects and efficacy.
    • OCs can have a wide range of adverse effects, including nausea, menstrual irregularity, and thromboembolic disorders.

    Oral Contraceptives (OCs)

    • OCs are available in monophasic, biphasic, and triphasic formulations, with different levels of estrogen and progestin.

    • OCs can decrease the risk of several disorders, including ovarian cancer, endometrial cancer, and acne.

    • OCs can interact with other drugs, including warfarin, hypoglycemic agents, and theophylline.

    • Some OCs contain levomefolate, a metabolite of folic acid, to reduce the risk of fetal neural tube defects.### Combination Oral Contraceptives (OCs)

    • Most OCs are taken in a repeating sequence of 21 days of active pills followed by 7 days of inactive pills or iron-containing pills.

    • The sequence can be started on the first day of the menstrual cycle or the first Sunday after the onset of menses.

    • With a Sunday start, backup contraception is recommended for the first 7 days.

    • Each dose should be taken at the same time every day to maintain effectiveness.

    Extended or Continuous Cycle OCs

    • 14 products are packaged and marketed for prolonged use, decreasing episodes of withdrawal bleeding and associated symptoms.
    • Successive dosing cycles should commence every 28 days, even if there is breakthrough bleeding or spotting.

    Missed Doses

    • If one or more pills are missed in the first week, take one pill as soon as possible and continue with the pack, using an additional form of contraception for 7 days.
    • If one or two pills are missed during the second or third week, take one pill as soon as possible and continue with the active pills, skipping the placebo pills and starting a new pack once all active pills have been taken.
    • If three or more pills are missed during the second or third week, follow the same instructions as above, using an additional form of contraception for 7 days.

    Progestin-Only OCs (Minipills)

    • Contain a progestin but no estrogen, making them safer than combination OCs but less effective.
    • Alter cervical secretions, making them thicker and stickier, and modify the endometrium, making it less favorable for implantation.
    • Taking the pill at the same time every day is crucial, as missing a dose by even 3 hours can reduce efficacy.
    • Backup contraception is recommended if unprotected sexual intercourse occurs.

    Transdermal Contraceptive Patch

    • Has the same mechanism as combination OCs, but with a more convenient dosing schedule (once a week).
    • Has the same contraceptive efficacy and incidence of breakthrough bleeding and spotting as combination OCs.
    • Adverse effects include breast discomfort, headache, local irritation, nausea, and menstrual cramps.

    NuvaRing

    • A hormonal contraceptive device designed for vaginal insertion, containing an estrogen/progestin combination.
    • Prevents pregnancy by suppressing ovulation.
    • Adverse effects, drug interactions, warnings, and contraindications are the same as for combination OCs.
    • Insertion is done by the user, and a new ring is inserted after a ring-free week.

    Nexplanon

    • A single 4-cm rod containing 68 mg of etonogestrel, a synthetic progestin, implanted subdermally in the arm.
    • Provides contraception for 3 years, with recent studies showing effectiveness up to 5 years.
    • Bleeding episodes are irregular and unpredictable, and bleeding irregularities are the leading reason for discontinuation.
    • Safe to use during breastfeeding after the 21st postpartum day.

    Depot Medroxyprogesterone Acetate (DMPA)

    • Given by injection intramuscularly or subcutaneously, protecting against pregnancy for 3 months or longer.
    • Inhibits the secretion of gonadotropins, thereby inhibiting follicular maturation and ovulation, thickening cervical mucus, and causing thinning of the endometrium.
    • Adverse effects include menstrual disturbances, mild weight gain, abdominal bloating, headache, depression, and decreased libido.
    • Poses a risk for reversible bone loss, but this risk does not outweigh the benefits of treatment.

    Intrauterine Devices (IUDs)

    • Among the most reliable forms of reversible birth control, with two main classes: hormone-free copper IUDs and levonorgestrel-containing IUDs.
    • Can cause cramping and alteration of menses, with main side effects including heavier menstrual bleeding and cramping for copper IUDs, and bleeding irregularities for levonorgestrel-containing IUDs.

    Spermicides

    • Chemical surfactants that kill sperm by destroying their cell membranes, available in various formulations.
    • When used alone, spermicides are only moderately effective, but combined use with a diaphragm or condom increases efficacy.
    • Adverse effects include vaginal irritation and dryness.

    Emergency Contraception (EC)

    • Defined as contraception implemented after intercourse, with safe and effective methods available for decades.
    • Can be accomplished in two basic ways: taking an emergency contraceptive pill (ECP) or inserting a copper-T IUD.
    • Three progestin-only products are available: Plan B One-Step, Next Choice One Dose, and Next Choice, which contain levonorgestrel.
    • Ulipristal acetate is another ECP that prevents conception primarily by suppressing ovulation.

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    Description

    Test your knowledge of common oral and transdermal estrogens like conjugated equine estrogens, estradiol, and estropipate, as well as estrogen/progestin combinations such as conjugated equine estrogens/medroxyprogesterone acetate and estradiol/norethindrone acetate.

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