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Progestin Androgenic Activity

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181. Benign Lesions of the Ovaries (Follow-up)

treatment options have been developed to combat endometriosis. Recommended medical therapies have included gestagens, oral contraceptive pills, nonsteroidal anti-inflammatory drugs (NSAIDs), and gonadotropin-releasing hormone (GnRH) analogues. [ , , ] Danazol, the isoxazole derivative of 17-alpha-ethinyl testosterone, was previously used and was effective, but it proved to have severe androgenic side effects and thus is no longer used. The goals of surgery are to restore normal pelvic anatomy, to remove (...) and is not the standard of care. Ovarian lesions in childhood Childhood is a time of busy activity for the ovaries, a fact that may be underrecognized by both gynecologists and pediatricians. Histologically, the ovarian stroma is growing, causing the ovaries to enlarge. When cysts manifest, they are usually small and simple. The incidence of simple cysts increases with age, and most are caused by a failure of the follicle to undergo involution. Not surprisingly, in this age group, most cysts are diagnosed

2014 eMedicine.com

182. Osteoporosis (Diagnosis)

trauma Pain is localized to a specific, identifiable, vertebral level in the midthoracic to lower thoracic or upper lumbar spine The pain is described variably as sharp, nagging, or dull; movement may exacerbate pain; in some cases, pain radiates to the abdomen Pain is often accompanied by paravertebral muscle spasms exacerbated by activity and decreased by lying supine Patients often remain motionless in bed because of fear of causing an exacerbation of pain Acute pain usually resolves after 4-6 (...) detail. Management Lifestyle modification for prevention of osteoporotic fractures includes the following [ ] : Increasing weight-bearing and muscle-strengthening exercise Ensuring optimum calcium and vitamin D intake as an adjunct to active antifracture therapy The NOF recommends that pharmacologic therapy should be reserved for postmenopausal women and men aged 50 years or older who present with the following [ ] : A hip or vertebral fracture (vertebral fractures may be clinical or morphometric [eg

2014 eMedicine Surgery

183. Contraception (Follow-up)

and progestin in each of the hormonally active pills. Phasic combinations can alter either or both hormonal components. Use should be initiated either on the first day of the menses or the first Sunday after menses has begun. Most of the formulations have 21 hormonally active pills followed by 7 placebo pills. This facilitates consistent daily pill intake. A French study found that among women taking combination oral contraceptive pills, those using a tailored regimen (pills taken daily until the occurrence (...) ). Seasonale contains a progestin (levonorgestrel) and an estrogen (ethinyl estradiol), which are active ingredients in already approved oral contraceptives. With the Seasonale dosing regimen, the expected menstrual periods that a woman usually experiences are reduced from once a month to approximately once every 3 months. As with the conventional 28-day regimen, women experience menses while taking placebo tablets. Although Seasonale users have fewer scheduled menstrual cycles, the data from clinical

2014 eMedicine.com

184. Gynecologic Pain (Diagnosis)

common causes are endometriosis, adenomyosis, and the presence of an intrauterine device. Pain starts 1-2 weeks prior to the onset of menses and persists for a few days after cessation of flow. Hypertonic uterine activity coupled with an excess of prostaglandins is postulated to be the cause of secondary dysmenorrhea. Patients are somewhat less responsive to nonsteroidal anti-inflammatory drugs (NSAIDs) and combination oral contraceptives compared with patients with primary dysmenorrhea. Presacral (...) a feeling that some sort of internal collision is occurring during sexual activity. Any pelvic pathology may be responsible for this discomfort, but abnormalities such as endometriosis, pelvic adhesions, pelvic relaxation, malposition (retroversion), adnexal pathology or prolapse, and uterine fibroids are the most likely causes. IC may cause dyspareunia before it proceeds to chronic unremitting pain. IBS may also cause dyspareunia and pain at the apex of the vagina. Adhesions A study using conscious

2014 eMedicine.com

185. Hormone Therapy</a> (Diagnosis)

) or systemic therapy (oral drugs, transdermal patches and gels, implants). Hormonal products available in such preparations may contain the following ingredients: Estrogen alone Combined estrogen and progestogen Selective estrogen receptor modulator (SERM) Gonadomimetics, such as tibolone, which contain estrogen, progestogen, and an androgen The estrogens most commonly prescribed are conjugated estrogens that may be equine (CEE) or synthetic, micronized 17β estradiol, and ethinyl estradiol. The progestins (...) : A history of breast cancer * A history of endometrial cancer * Porphyria Severe active liver disease Hypertriglyceridemia Thromboembolic disorders Undiagnosed vaginal bleeding Endometriosis Fibroids * Note that many clinicians do not prescribe HT for women with a previous history of breast or endometrial cancer. Adverse effects and risks Possible transient adverse effects are as follows: Nausea Bloating, weight gain (equivocal finding), fluid retention Mood swings (associated with use of relatively

2014 eMedicine.com

186. Benign Lesions of the Ovaries (Diagnosis)

treatment options have been developed to combat endometriosis. Recommended medical therapies have included gestagens, oral contraceptive pills, nonsteroidal anti-inflammatory drugs (NSAIDs), and gonadotropin-releasing hormone (GnRH) analogues. [ , , ] Danazol, the isoxazole derivative of 17-alpha-ethinyl testosterone, was previously used and was effective, but it proved to have severe androgenic side effects and thus is no longer used. The goals of surgery are to restore normal pelvic anatomy, to remove (...) and is not the standard of care. Ovarian lesions in childhood Childhood is a time of busy activity for the ovaries, a fact that may be underrecognized by both gynecologists and pediatricians. Histologically, the ovarian stroma is growing, causing the ovaries to enlarge. When cysts manifest, they are usually small and simple. The incidence of simple cysts increases with age, and most are caused by a failure of the follicle to undergo involution. Not surprisingly, in this age group, most cysts are diagnosed

2014 eMedicine.com

187. Uterine Cancer (Diagnosis)

therapy or tamoxifen use. Tamoxifen increases endometrial cancer risk by its agonist activity on the estrogen receptors on the endometrial lining. Endogenous estrogen sources include obesity and (PCOS) with anovulatory cycles, or estrogen-secreting tumors such as granulose cell tumors. Increasing body mass index has been associated with increasing risk of endometrial cancer. [ ] Research has found a relative risk of 3 in women 21-50 lb overweight and relative risk over 10 in women more than 50 lb (...) overweight. Androstenedione is converted to estrone, and androgens are aromatized to estradiol in the adipose tissue, leading to higher levels of unopposed estrogen in obese women. See Table 1. Table 1. Factors Contributing to Endometrial Cancer Risk Factor Number of Folds Increased Risk Estrogen only hormone replacement therapy (HRT) 2-10 Obesity 2-20 PCOS, chronic anovulation 3 Tamoxifen 2-3 Nulliparity 2-3 Early menarche, late menopause 2-3 Hypertension, diabetes 2-3 The other factors associated

2014 eMedicine.com

188. Menopause (Diagnosis)

for CAD prevention. Administration routes for hormone therapy are as follows: Oral Transdermal Topical Vaginal route cream, ring, or tablet for vaginal symptoms Contraindications for estrogen therapy include the following: Undiagnosed vaginal bleeding Severe liver disease Pregnancy Venous thrombosis Personal history of breast cancer Well-differentiated and early endometrial cancer, once treatment for the malignancy is complete, is no longer an absolute contraindication. Progestins alone may relieve (...) lipoprotein (LDL), and apolipoprotein B levels, in conjunction with loss of the protective effect of high-density lipoprotein (HDL), is characteristic in menopause. [ , , ] With cessation of ovulation, estrogen production by the aromatization of androgens in the ovarian stroma and estrogen production in extragonadal sites (adipose tissue, muscle, liver, bone, bone marrow, fibroblasts, and hair roots) [ ] continue, unopposed by progesterone production by a corpus luteum. Consequently, perimenopausal

2014 eMedicine.com

189. Menorrhagia (Diagnosis)

related by a patient with menorrhagia often can be more revealing than laboratory tests. A detailed patient history is imperative and should include inquiries about the following: Exclusion of pregnancy (the most common cause of irregular bleeding in women of reproductive age and the first diagnosis that should be excluded before further testing or drug therapy) Quantity and quality of bleeding Age Pelvic pain and pathology Menses pattern from menarche Sexual activity (intrauterine device [IUD (...) : Signs of severe volume depletion (eg, anemia) Obesity Signs of androgen excess (eg, hirsutism) Ecchymosis Purpura Pronounced acne General examination should include evaluation of the following: Visual fields Bleeding gums Thyroid evaluation Galactorrhea Enlarged liver or spleen Pelvic examination should evaluate for the following: Presence of external genital lesions Vaginal or cervical discharge Uterine size, shape, and contour Cervical motion tenderness Adnexal tenderness or masses (especially

2014 eMedicine.com

190. Malignant Lesions of the Ovaries (Diagnosis)

with abnormal gonads. They may have a 46XY karyotype with pure gonadal dysgenesis or androgen insensitivity syndrome, or, they may have a 45X, 46XY karyotype with mixed gonadal dysgenesis. Dysgerminomas may be large and usually are solid, with a smooth external surface and a fleshy pink-tan color inside. The majority are confined to the ovary at diagnosis, but approximately 25% of otherwise stage I dysgerminomas have lymph node metastasis. For more information, see . Cystic teratoma Teratomas are germ cell (...) and Sertoli-Leydig cell tumors less so, they behave in a much less malignant fashion than epithelial ovarian cancers. Benign tumors in the group include thecoma and fibroma. Granulosa cell tumors and pure Sertoli cell tumors commonly secrete estrogen, while Leydig cell tumors and combined Sertoli-Leydig tumors often secrete androgens. Granulosa cell tumor This is the most common malignant sex-cord stromal tumor. Ninety percent of granulosa cell tumors are stage I at the time of diagnosis. This tumor

2014 eMedicine.com

191. Low Energy Availability in the Female Athlete (Diagnosis)

=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMzEyMzEyLW92ZXJ2aWV3 processing > Low Energy Availability in Female Athletes Updated: Sep 19, 2016 Author: Stephen Kishner, MD, MHA; Chief Editor: Stephen Kishner, MD, MHA Share Email Print Feedback Close Sections Sections Low Energy Availability in Female Athletes Overview Overview Since the introduction of title IX in 1972, which barred discrimination based on sex with regard to educational programs and activities receiving federal financial assistance, there have been increased opportunities for females (...) should be considered if a patient's reproductive function is not restored with a trial of increased energy intake or if the findings on history and physical exam suggest other causes of . If the patient has signs of hyperandrogenism ( ), free and total testosterone can be tested to assess for androgen excess. [ ] In a 2016 study by Łagowska et al, nutritional status and dietary habits were analyzed in relation to testosterone levels in female athletes and ballet dancers with menstrual disorders

2014 eMedicine.com

192. Amenorrhea, Primary (Diagnosis)

steroids. Patients with this disorder who experience primary amenorrhea can be either genotypic males (XY) or females (XX). [ ] Complete androgen insensitivity syndrome is caused by a defective androgen receptor. Although patients with this syndrome have a 46,XY karyotype and produce testicularly derived testosterone, the testosterone cannot activate cellular transcription; therefore, the patient has female external genitalia. In most cases the disorder is X-linked. The testes, located internally (...) into the circulation and communicates with the granulosa cells surrounding the developing oocytes. As FSH increases during the early portion of the follicular phase, it meshes with granulosa cells to stimulate the aromatization of androgens into estradiol. The increase in estradiol and FSH leads to an increase in FSH-receptor content in the many developing follicles. Over the next several days, the steady increase of estradiol (E 2 ) levels exerts a progressively greater suppressive influence on pituitary FSH

2014 eMedicine.com

193. Dysfunctional Uterine Bleeding (Diagnosis)

induce a return to normal endometrial growth Progestins: Chronic management of AUB requires episodic or continuous exposure to a progestin Desmopressin: A synthetic analogue of arginine vasopressin, desmopressin has been used as a last resort to treat abnormal uterine bleeding in patients with documented coagulation disorders Hysterectomy Abdominal or vaginal hysterectomy may be necessary in patients who have failed or declined hormonal therapy, who have symptomatic anemia, and who are experiencing (...) in endometrial tissue mechanisms, other forms of uterine pathology, or systemic causes might be implicated. Anovulatory cycles are associated with a variety of bleeding manifestations. Estrogen withdrawal bleeding and estrogen breakthrough bleeding are the most common spontaneous patterns encountered in clinical practice. Iatrogenically induced anovulatory uterine bleeding might occur during treatment with oral contraceptives, progestin-only preparations, or postmenopausal steroid replacement therapy

2014 eMedicine.com

194. Contraception (Diagnosis)

and progestin in each of the hormonally active pills. Phasic combinations can alter either or both hormonal components. Use should be initiated either on the first day of the menses or the first Sunday after menses has begun. Most of the formulations have 21 hormonally active pills followed by 7 placebo pills. This facilitates consistent daily pill intake. A French study found that among women taking combination oral contraceptive pills, those using a tailored regimen (pills taken daily until the occurrence (...) ). Seasonale contains a progestin (levonorgestrel) and an estrogen (ethinyl estradiol), which are active ingredients in already approved oral contraceptives. With the Seasonale dosing regimen, the expected menstrual periods that a woman usually experiences are reduced from once a month to approximately once every 3 months. As with the conventional 28-day regimen, women experience menses while taking placebo tablets. Although Seasonale users have fewer scheduled menstrual cycles, the data from clinical

2014 eMedicine.com

195. Hormone Therapy</a> (Treatment)

) or systemic therapy (oral drugs, transdermal patches and gels, implants). Hormonal products available in such preparations may contain the following ingredients: Estrogen alone Combined estrogen and progestogen Selective estrogen receptor modulator (SERM) Gonadomimetics, such as tibolone, which contain estrogen, progestogen, and an androgen The estrogens most commonly prescribed are conjugated estrogens that may be equine (CEE) or synthetic, micronized 17β estradiol, and ethinyl estradiol. The progestins (...) : A history of breast cancer * A history of endometrial cancer * Porphyria Severe active liver disease Hypertriglyceridemia Thromboembolic disorders Undiagnosed vaginal bleeding Endometriosis Fibroids * Note that many clinicians do not prescribe HT for women with a previous history of breast or endometrial cancer. Adverse effects and risks Possible transient adverse effects are as follows: Nausea Bloating, weight gain (equivocal finding), fluid retention Mood swings (associated with use of relatively

2014 eMedicine.com

196. Spontaneous Primary Ovarian Insufficiency and Premature Ovarian Failure (Treatment)

is not only a reproductive organ but is also a source of important hormones that help maintain strong bones. Adequate replacement of these missing hormones, a healthy lifestyle, and a diet rich in calcium are essential. POI/POF is not menopause. Spontaneous ovarian activity and pregnancies are possible. Allow the patient enough time to accept the diagnosis. Family planning decisions are best made after the patient has had some time to come to terms with her condition. No proven therapies exist to restore (...) fertility; experimental treatment should be performed only under a review board–approved research protocol. Currently available options to resolve infertility include change of family building plans, such as adoption, ovum donation, or embryo donation. Hormone therapy (HT) All women with POI/POF should receive cyclical HT with estrogens and progestins to relieve the symptoms of estrogen deficiency and to maintain bone density. A few women may need HT even before amenorrhea develops to alleviate

2014 eMedicine.com

197. Surgical Management of Mullerian Duct Anomalies (Treatment)

and that the sinovaginal bulbs are formed by the caudal wolffian ducts. They also concluded that in the mouse vaginal development is under negative control of androgens. [ ] Similar observations in an analysis of human embryos support these findings. The embryos ranged from Carnegie stage 18 to 23. In all 7 examined embryos, the caudal müllerian duct was intimately connected to the wolffian duct by a common basal membrane and the caudal aspect of the fused müllerian duct separated and returned to the respective (...) similar to DNA from the control population. [ ] One report discusses a de novo translocation in a young woman with MRKH syndrome, suggesting that this break point may be involved in midmüllerian differentiation. [ ] A loss-of-function mutation in the WNT4 gene was identified in an 18-year old woman with MRKH syndrome, unilateral renal agenesis, and androgen excess with virilization. The WNT4 gene encodes for a secreted protein that suppresses male sexual differentiation. In mice, the corresponding

2014 eMedicine.com

198. Osteoporosis (Secondary) (Treatment)

with clinically recognized osteoporosis, clinicians should offer bisphosphonate therapy to reduce the risk of vertebral fracture; evidence is lacking on BMD monitoring in men. Nonpharmacologic preventive measures include modification of general lifestyle factors, such as increasing weight-bearing and muscle-strengthening exercise, which epidemiologic studies have linked to lower fracture rates, and ensuring optimum calcium and vitamin D intake as adjunct to active antifracture therapy. [ ] In addition (...) by the FDA in October 2013 for prevention of osteoporosis and treatment of vasomotor symptoms in postmenopausal women. Combining a SERM with CEs lowers the risk of uterine hyperplasia caused by estrogens. This eliminates the need for a progestin and its associated risks (eg, breast cancer, myocardial infarction, venous thromboembolism). In clinical trials, this combination decreased bone turnover and bone loss in postmenopausal women at risk for osteoporosis. Bone mineral density increased significantly

2014 eMedicine.com

199. Osteoporosis (Primary) (Treatment)

with clinically recognized osteoporosis, clinicians should offer bisphosphonate therapy to reduce the risk of vertebral fracture; evidence is lacking on BMD monitoring in men. Nonpharmacologic preventive measures include modification of general lifestyle factors, such as increasing weight-bearing and muscle-strengthening exercise, which epidemiologic studies have linked to lower fracture rates, and ensuring optimum calcium and vitamin D intake as adjunct to active antifracture therapy. [ ] In addition (...) by the FDA in October 2013 for prevention of osteoporosis and treatment of vasomotor symptoms in postmenopausal women. Combining a SERM with CEs lowers the risk of uterine hyperplasia caused by estrogens. This eliminates the need for a progestin and its associated risks (eg, breast cancer, myocardial infarction, venous thromboembolism). In clinical trials, this combination decreased bone turnover and bone loss in postmenopausal women at risk for osteoporosis. Bone mineral density increased significantly

2014 eMedicine.com

200. Osteoporosis (Treatment)

with clinically recognized osteoporosis, clinicians should offer bisphosphonate therapy to reduce the risk of vertebral fracture; evidence is lacking on BMD monitoring in men. Nonpharmacologic preventive measures include modification of general lifestyle factors, such as increasing weight-bearing and muscle-strengthening exercise, which epidemiologic studies have linked to lower fracture rates, and ensuring optimum calcium and vitamin D intake as adjunct to active antifracture therapy. [ ] In addition (...) by the FDA in October 2013 for prevention of osteoporosis and treatment of vasomotor symptoms in postmenopausal women. Combining a SERM with CEs lowers the risk of uterine hyperplasia caused by estrogens. This eliminates the need for a progestin and its associated risks (eg, breast cancer, myocardial infarction, venous thromboembolism). In clinical trials, this combination decreased bone turnover and bone loss in postmenopausal women at risk for osteoporosis. Bone mineral density increased significantly

2014 eMedicine.com

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