Hyperprolactinemia:/Excess/prolactin/secretion/
Physiological/etiology:/Pregnancy/////////////Early/Nursing/////////////////////Stress/
Pathologic/etiology:/Prolactinoma:/Pituitary/adenoma/producing/prolactin//
How/to/block/section/of/prolactin/Dopamine/=/PIF/(prolactin/inhibiting/Factor)/
Tumor/Dection:/MRI/or/CT/scan/
Diagnosis:// Normal/prolactin/level/in/<20ng/ml/
Moderate/elevation/30N300ng/ml/(Pregnancy)/
Women:/detected/early/usually/(microadenoma)/Bc/slight//
increase/in/prolactin/30N300ng/ml/produce/symptoms/
/
Galactorrhea/(milk/discharge)/Irregular/menses/or/amenorrhea/
Men:/Detected/late/(macroadenoma)/>500ng/ml/
Loss/of/sex/hormone/
Visual/loss:/bitemporal/hemianopia!compression/@chasm/
Gynecomastia/
Treatment:/dopamine/agonist/(80%/of/prolactinoma/respond)//
Bromocriptine//
Pergolide/
Carbergoline/
Excess/of/growth/hormone!Bony/and/soft/tissue/overgrowth//
Acromegaly:/abnormal/growth/of/cartilage/and/bone/tissue(Adults)/
Gigantism:/abnormal/linear/growth/(Children/)/
Etiology://Tumor/(pituitary/adenoma)/producing/growth/hormone/
Enlargement/of/hands/and/feet,/nose/and/mandible/
Entrapment/neuropathies/(CTS!/carpal/tunnel/syndrome)/
Diabetes/and/Hypertension/
Visual/loss/(bitemporal/hemianopsia)//
Diagnosis:/Screening/test:/Measure/GH/after/100g./Glucose/normal/if/GH<5ng/ml/
////////////////
Measurement/of/IGFN1/SMC/(InsulinNlike/GF/1//somatomedin/C)/
Correlate/with/disease/activity/
Tumor/Detection:/MRI/or/CT/scan/
st
Treatment/1 /Surgery/(Best/response)/
nd
2 /best:/Octreotide:somatostatin/analogue/hypothalamic/hormone/that/acts/on.//
Anterior/pituitary:/Inhibit/release/GH,/2/3/pt/will/become/normal/
Acromegaly/
GI/tract:/Decrease/GI/motility/Rx/of/…/
Carcinoid/tumors/
Esophageal/varices/
Gastrinoma/
Glucogonoma/
rd
3 /choice:/Bromocriptine/(dopamine/agonist/=/PIH)/
New$(2003)$FDA$approved$drug$from$acromegaly:$Pegvisomant$GHr$antagonist$$
Side/effects:/Flu/syndrome/and/Back/pain//
Pituitary/GH/deficiency/:/Not/enough/GH/(dwarfism/–/short/stature/and/adiposity)//
Recombinant/human/growth/H/(rhDH):/Somatrem/and/Somatropin/
Mecasermin/(recombinant/human/IGFN1)//
Indications:/Growth/failure/in/pediatric/patients…/
Prader/Willi/syndrome/(paternal/loss/of/function/chr/15/
Turner’s/syndrome,//
CRF/in/children/
////////Wasting/in/patients/with/AIDS/
/
/
////////AntiNaging//
Diseases/of/the/posterior/pituitary:/ADH/(arginine/vasopressin),/oxytocin/
Arginine/Vasopressor/Receptors/
/////V1/(AVPR1A):/GNcoupled/proteins/that/activates/IP3/and/DAG/
//////////Found/mainly/in/blood/vessels!////Activation/leads/to/vasoconstriction//
/////V2(AVPR2):/GNcoupled/proteins/that/activates/adenylate/cyclase/
//////////Found/mainly/in/the/collecting/ducts/of/the/kidney/to/concentrate/the/urine/
//////////Inc/water/permeability/and/resorption/in/the/CD/–/maintains/homeostasis/
//////////Blockage/will/cause/nephrogenic/DI/
Diabetes/insipidus:/Deficiency/of/ADH/(Vasopressin)/
No/ADH/!/(you/pee/a/lot)/Polyuria!/Polydipsia/(Excessive/thirst)/
Increase/Hypernatremia/bc/can’t/keep/water/so/your/blood/get/salty/
/
Central/DI/:/I/don’t/have/ADH/
/
Nephrogenic/DI://I/have/ADH/but/
Problem:/Hypothalamus//
the/kidney/is/not/responding///
Rx:/Vasopressin/or/Desmopressin/SQ///
Problem:/Kidney/
/
/
/
/
Rx:/Hydrochlorothiazide/a/diuretic…/
Decreases/plasma/volume,/as/does/blood/
vol/decreases/the/GFR/utimatly/dec/urine,/
Kidney/works/better../
/
/
Adrenal(Glands(…Hormones/secreted/by/the/adrenal/cortex…(
1.
Mineralcorticoids/(Aldosterone)N/Glomerulosa/
2.
Glucocorticoids/(Cortisol)NFasiculata//
3.
Androgens/(Testosterone)NReticularis//
(
Cushing’s(syndrome:(exogenous/MC/cause/overall/prolonged/use/of/steroids/ACTH/too/much/
cortisol/
Clinical/suspicion:/Moon/face,/osteoporosis,/DM,/amenorrhea/they/are/going/to/come/to/clinic/
give/overnight/dexamethasone/suppression/test…/it/comes/back/Abnormal/
//
give/low/dose/dexmethasone/suppression/test/…/comes/back/Abnormal:/Cushing/////
///////////
If/it/comes/back/normal/you/Order/high/dose/dexamethasone/suppression/test/
If/suppression:/It’s/adrenal/hyperplasia/due/to/pituitary/ACTH/(secondary)/Pituitary/adenoma///
If/no/response/it/is/adrenal/neoplasia:/Ectopic/ACTH/producing/tumor/!Measure/ACTH/
/
If/Low:/It/is/Primary/adrenal/neoplasia///
/
/
If/high:/it/is/tumor/(e.g./Oat/cell/carcinoma)/
/
Drugs/used/in/Cushing’s:/Corticosteroids/antagonists/
1.
Aminoglutethimide:/Inhibits/the/conversion/of/cholesterol/to/pregnenolone/
2.
Metyrapone:/Inhibits/11/BetaNhydroxylase/
3.
Trilostane:/Inhibits/3BNDehydrogenase/
(
Addison’s(disease:(Too(little(Cortisol((Chronic(adrenocortical(insufficiency)(
Cause:/Idiopathic/atrophy/of/the/gland,/infection,/cytotoxic/drugs/
Clinical/findings:/weakness,/fatigue,/weight/loss,/Hypotension/
Hyperpigmentation(of(the(skin:/tan/or/bronze/darkening/of/skin/(unN)/exposed/a/
Diagnosis:/Plasma/cortisol/is/low/
Urinary/free/cortisol/is/low/
Blood/glucose/is/low/
/
Drugs/indicated/for/Addison’s/disease:/“glucocorticoid/first”/
Glucocorticoids(classification://
1.
Short/acting:///Hydrocortisone/(cortisol)/
2.
IntermediateNacting/
PrednisoneN/asthma//
Prednisolone/
Methyprednisolone/
3.
LongNacting:/Dexamethasone/(betamethasone)/Stimulation/of/fetal/lung/
maturation/…lung/suppression/test/
(
Topical(glucocorticoids:/
1.
Beclomethasone/
2.
Budesonide/
3.
Fluticasone/
(
Adverse(effects(of(corticosteroids****(
1.
Osteoporosis/
2.
Peptic/ulcers/
3.
Edema/
4.
Precipitation/of/diabetes,/hypertension/
5.
Suppression/of/Hypothalamic/Pituitary/Axis/
/
General(principles(of(corticosteroids(therapy(
1.
Long/term/treatment/–/HPA/suppression/
2.
Abrupt/cessation/–/w/drawal/syndrome/–/malaise,/fever,/weakness,/joint/
pain/
3.
Reactivation/of/disease/
4.
Gradual/tapering/of/the/dose/
(
ISecond/line/mineralcorticoids://Fludrocortisone//give/in/renal/insufficiency//
(
Adrenal(Crisis((acute(adrenal(insufficiency)(
Fever,/abdominal/pain,/altered/mental/status,/vascular/collapse/
Rx:/IV/fluid/–/correction/of/fluid/and/electrolyte/abnormalities//
///////IV/glucocorticoid/
/
Non(endocrinal(uses(of(corticosteroids/
1.
Rheumatoid/arthritis/
2.
CollagenNvascular/disorders:/Gout/
3.
Severe/allergic/reactions/
4.
Gastrointestinal/diseases:/Inflammatory/bowel/disease/“flare/up”/
5.
Stimulation/of/lung/maturation/in/the/fetus//Betamethasone/
6.
Reduces/the/incidence/of/resp/distress/syndrome/in/infants/delivered/premature/
/
SIADH/=/too/much/ADH/pt/gets/Hyponatremia,/elevated/urine/osmolality/
Treatment:/Fluid/restriction/and/ADH/receptors/antagonist://
Demeclocycline/(antibiotic:/tetracycline),//
/
SE/Photosensitivity/
/
Tooth/and/bone/abnormality/
/
Nephrogneic/DI/
Used/as/…/
Blocks/both/Conivaptan/Newly/FDA/approved/for/Rx/of/hyponatremia/
Selective(V2(antagonist:(Tolvaptan:///FDA/approval/pending/
/
Parathyroid(Gland(Secrete/PTHormone/(Parathormone)/!/inc/Ca/level/(hypercalcemic)(
Bone:/Increases/bone/resorption/
Kidney:/inc/the/reabsorption/of/Ca/and/reduces(phosphate/
/
Intestines:/Indirectly/increases/absorption/of/calcium/
Primary(hyperparathyroidism:(Common/cause/(90%)/of/hypercalcemia(
Cause:/Solitary(adenoma/!/increase/PTH/!/increase/Ca++(
Secondary(hyperparathyroidism/Ca++/is/too/low/!/increase/PTH/
/
Cause:/Chronic/Kidney/Failure/
(
Clinical(finding(in(hypercalcemia:/Stones,/bones,/moans,/and/groans/
involves/multiple/organs/and/systems/Renal/musculoskeletal,/GI,/and/Neuro/
(
Diagnosis:/Serum/Ca++/>/10.2/mg/dL/with/elevated/PTH/level//
/
Drugs/used/in/Rx/of/primary/hyperparathyroidism/
(((((Calcitonin/Hormone/that/decreases/calcium/level/
/////Bisphosphonates/ending/in/‘dronate’”/
IV/“drugs”/ /
/
Oral(Rx/of/osteoporosis(
Etidronate( (
(
Alendronate(
Pamidronate(–EMG(HyperCal(
Ibandronate(
Zoledronic(acid((
(
Risedronate((Pagets/disease)/
FDA/approved/for/hypercalcemia/of//
malignancy/–/Multiple/Myeloma/
(
Mechanism/of/bisphosphonates://Prevent/bone/resorption/
Reduce/the/formation/and/dissolution/of/hydroxyapatite/crystals/
Site/of/action:/Osteoclasts(
/
New/treatment/of/osteoporosis/“Recombinant/PTH”/Teriparatide//
/
Emergency/treatment/for/severe/hypercalcemia//Ca++/>/15mg/dL/
Saline/diuresis/–/IV/normal/saline/
Furosemide/only/if/CHF/
IV/Pamidronate/(Bisphosphanates)/
Calcitonin,/gallium/nitrate(
/
++
Primary(Hypoparathyroidism((Hypocalcemia)/////↓PTH/!/↓Ca /↑PO4/
Most/common/cause/of/hypoparathyroidism:/Surgical/removal//of/the/parathyroid//
/
++
Pseudohypoparathyroidism//↓Ca !↑PTH/↑PO4…/Vitamin/D/is/low/
Abnormal/target/tissue/response/to/PTH…/receptors/are/defective/
Causes:/genetic/–/Type/Ia,/Type/Ib,/Type/II/
Clinical/finding://///Tetany:/Involuntary/contraction/of/muscle”/
//////////EKG:/QT/prolongation/
Rx:(IV(calcium(gluconate(
(
Thyroid(gland/Function://Secretion/of/T4/(thyroxineN/stored/form/)///
T3/(triiodothyronineNactive/form)/
in/plasma/are/reversibly/bound/to/protein/thyroxineNbinding/globulin/~/99.7%/of/both/=bound/
100%/T4/made/in/the/thyroid/gland/ 20%/of/T3/made/in/the/thyroid,/80%/peripherally/
(
Regulation(of(thyroid(hormone(Synthesis/
Hypothalamus/(TRH)/!/Anterior/Pituitary/(TSH)/!/Thyroid/!/↑T4/and/T3/
T4/and/T3/have/negative/feedback/to/anterior/pituitary/and/hypothalamus/
(
Thyroid(hormone(synthesis(
1.
Uptake/of/Iodide/(iodide/trapping)/
2.
Iodide/organification/(oxidation/iodination)/!/thyroid/perioxidase*/
3.
Coupling/of/MIT/and/DIT/
4.
Secretion/of/thyroid/hormones/
5.
Conversion/of/T4/to/T3//
/
Preparations:(Levothyroxine((T4),(Liothyronine(T3),(Liotrix(combination(T3,(T4)(
Levothyroxine(T4)(is(drug(of(choice(due(to(long(halfTlife/less/potent/than/Liothyronine(T3)(
Liothyronine/used/for/(Myxedema/coma)/!causes/cardiotoxicity;//
/
Use:/Hypothyroid,/Adult,/Childhood,/Infancy/–/cretinismNgrowth/retardation(physical,/mental)/
/
Hashimoto’s(disease://MC/cause/of/hypothyroidism/and/nonNtoxic/goiter/
Autoimmune/destruction/of/thyroid….Chronic/thyroiditis/
Antimicrosomal/and/antiNthyroglobulin/antibodies//Rx!/Levothyroxine/(T4)/
/
Myxedema(Coma:/Severe/long/standing/hypothyroidism/
Precipitating/Factors,/caused/by:/Cold/exposure,/Infection,/and/trauma/
Clinically/present/:/Hypothermia,/and/Respiratory/depression../
Treatment:// Intubation/and/mechanical/ventilation/
Control/Hypothermia/
Levothyroxine/I.V/or/Liothyronine/I.V/
SE:/Bc/too/much/TH//inc/activity//
Tachycardia,//
Heat/intolerance//
Tremors/
Arrthymia//
5`/doiodenase(T4!T3)/peripheral/conversion///
5/Deiodenase(T4!RT3)/activated/when/need/to/save/energy…ie/sick/
Antithyroid(Drugs(
Thioamides:/Inhibit/thyroid/peroxidase///Block/iodine/oxidation/and/Coupling/of/MIT/and/DIT//
1.
Methimazole/
2.
Carbimazole//
3.
Propylthiouracil/(PTU)–/inhibit/peripheral/conversion/of/T4/to/T3//
Block/synthesis/T3/and/T4/no/release,/therefore/slow/onset/of/action//
preferable/in/pregnancy:/(protein/bound,/so/does/not/cross/placenta)/
/
Toxicity:///Maculopapular/pruritic/rash/
3
((((((*Agranulocytosis/(granulocyte/count/</500/cells/mm )/
((/!/may/develop/opportunistic/infection/
(
(((((((HepaticNtoxicity//
/
131
Radioactive(Iodine(( I)(
NRapidly/absorbed/(orally)/
NConcentrated/in/thyroid/
NEmits/beta/radiation/!/destruction/of/thyroid/gland//
/
Preferred/treatment/for/most/patients/over/21/years/of/age/In/patients/without/heart/disease/
Advantage:/Inexpensive,/simple/outpatient/basis./No/surgical/risk./***Permanent/cure/
Disadvantage:/Response/slow,/hypothyroidism,/C/I/in/pregnancy/and/young/patients/
(
Uses(of(Antithyroid(drugs(
Hyperthyroidism/
Grave’s/disease:/Most/common/cause/of/hyperthyroidism,/women/between/30N40/
Diffuse/toxic/goiter/–/Thyrotoxicosis/
Autoimmune/disorder,/thyroid/stimulating/immunoglobulin/autoab/against/TSH/receptor/
/
Toxic(multinodular(goiter:(Plummer’s(disease//Not/autoimmune//////////////////
Look/for/elderly/client/
Arrythmia/and/congestive/heart/failure/
Treatment/of/choice:/radioactive/iodine/
(
Iodine(and(Iodides(
Lugol’s/Iodine/Na/Iodide,/K/Iodide/
The/iodinated/contrast/agents/–/diatrizoate/and/iohexol/
/
Mechanism://
NInhibit/hormone/release/
NDecrease/the/vascularity,/size,/and/fragility/of/a/hyperplastic/gland,/making/the/drugs/
valuable/as/preoperative/preparation/for/surgery./
NImprovement/in/thyrotoxic/symptoms/occurs/rapidly$–$within$2D7$days/
**Thyoid/escape:/Gland/will/escape/from/iodide/block/in/2/–/8/weeks/initall/they/ioidtes/would/
but/the/later/the/gland/becomes/risetant/to/the/drug/
/
Toxicity:// Conjunctivitis/
Rhinorrhea//
Swollen/salivary/glands/
Mucous/membrane/ulcerations/
Acneiform/rash/
Rarely,/anaphylactoid/reactions/
Radiation(exposure(and(the(thyroid:/risk/for/cancer/
Drugs/indicated:/Potassium/iodide/
(
Anion(inhibitors/!/Block/uptake/of/iodide/by/the/gland//
Through/competitive/inhibition/of/the/iodide/transport/mech//
Used/in/Amiodarone/induced/hyperthyroidism/
1.
Perchlorate/(CIO4N)/
2.
Pertechnetate/(TcO4N)/
3.
Thiocyanate/(SCNN)/
/
AdrenoceptorT(Blocking(Agents(Metoprolol,(atenolol,(propranolol(T5`(deiodinase((
Block/the/symptoms/of/thyrotoxicosisN/sympathetic/stim/–/palpitation,/nervousness,/tremors//
/
Thyroid(storm:(An(extreme(form(of(thyrotoxicosis/
Precipitating/factors:/Delirium,/tachycardia,/and/high/fever/
Supportive/therapy:/Hydration,/steroids,/O2/and/cooling/blanket/
Therapy/for/thyrotoxicosis//
Propanolol*/
Diltiazem/
Potassium$iodide*/or/iodinated/contrast/media/
Propylthiouracil*/or/methimazole*/
Hydrocortisone/
/
th
th
Subacute(thyroiditis:(Viral(
More/common/in/4 /and/5 /decade/w(elevated$ESR$(
Here/T4/and/T3/are/initially/high/due/to/leakage/of/thyroid/hormone/
Hyperthyroidism/!/Hypothyroidism//
RAIU$is$lowD$Radioactive$iodine$uptake$test$
Treatment:/Symptomatic//
/
/
/
Hypopituitarism:/Partial/or/complete/loss/of/Anterior/pituitary/function/
Look/for/tired,/quiet/people/
♥
Gonadotropin/deficiency/(LH/and/FSH)/lost/early/
♥
GH/deficiency/
♥
TSH/def/!/Hypothyroidism,/fatigue,/cold/intolerance/w//out/goiter/
♥
ACTH/deficiency//
Young/female/postNpartum/w/inability/to/lactate/due/to/hypopituitarism//aka…./
“Sheehan’s/syndrome”/due/to/high/amount/of/bleeding/in/the/pituitary/(bc/blood/supply/dec/
so/much/bleeding/during/delever/or/after!/there/is/postiblity/fo/infarction//)/
Pituitary/apoplexy/=Infarction/or/Hemorrhage/of/a/pituitary/adenoma/
Inflammatory/diseases/
Oxytocin/facilitate/stimulates/labor,/uterine/contration,/lactation,controles/uterine/hormone//
Clinical/uses:/To/induce/labor…..To/augment(help/w)/delayed/labor/
/To/control/of/uterine/hemorrhage/after/vaginal/or/cesarean/delivery/
Toxicity:/Excessive/stimulation/of/uterine/contraction/before/delivery/can/cause/fetal/distress,//
///////////////placental/abruption,/or/uterine/rupture/
/
Hypothalamic(hormones(Gonadotropin(releasing(hormones((GnRH)(and/its/analogs(
(((((Gonadorelin///Pulsatile/intravenous/administration/stimulates/FSH/and/LH/secretion/
1. Stimulation(pulsatile(of(gonadrotropin(production…Infertility/(both/male/and/female)(
(((((Goserelin,(Histerlin,(leuprolide,(nagarelin,(triptorelin(
//////////Continued/presence/of/GnRH/results/in/an/inhibitory/action//
//////////drop/in/the/concentration/of/gonadotropins/
2. Suppression(of(gonadotropin(production….Assisted/reproductive/technology/cont/
3. Endometriosis/(Give/drug/continuously)…Reduces/[estrogen/progesterone]//
4. Uterine(Leiomyoma((Fibroids)(!fibroids/grow/when/stimulated/by/estrogen(
/This/Reduces/fibroid/size/
5. To(Stop(Central(precocious(puberty(
6. Prostate(cancer…Combined/antiandrogen/therapy/w/continuous/(
GnRH/agonist/and/an/androgen/GnRH(receptor(antagonists:/Used/to/prevent/the/
LH/surge/during/controlled/ovarian/hyperstimulation//
/
1.
Ganirelix,(Cetroreli(
(
Gonadotropins((Anterior(pituitary):((Biphasic:/can/either/stimulate/or/suppress(
1.
FollicleNStimulating/Hormone:/Menotropins//
Urofollitropin/(from/urine/postNmenopausal/women)/
Follitropin(alfa/(synthetic)/
Follitropin(beta/(synthetic)/
2.
Luteinizing/Hormone:/Lutropin/
3.
Human/Chorionic/Gonadotropin/produced/by/the/human/placenta/
(
Clinical(Uses(
1.
Ovulation/induction/both/in/general/and/in/women/with/anovulation/
Hypogonadotropic/hypogonadism,/Polycystic/ovary/syndrome,/Obesity/
2.
Controlled/ovarian/hyperstimulation…Assisted/reproductive/technology/procedu/
3.
Male/infertility/
Toxicity:/Multiple/pregnancies//
Ovarian/hyperstimulation/syndrome:/ovarian/enlargement,/ascites,/hydrothorax/
(
Sex/Hormones/
Hypothalamus/(GnRH)/!/Pituitary/gland/(FSH/and/LH/–/gonadotropins)/!/
1.
Ovaries/(estrogen/and/progesterone)/!/Endometrium/–/menstruation/
2.
Testes/(Testosterone)//
(
Estrogens/
1.
Primarin/(natural)/Estradiol/
2.
Ethinyl/estradiol/and/Mestranol/(steroids)/
3.
DES/(Non/steroids)/DiEthylStilbestrol/
/
Indications:/Contraception/
///////////Primary/hypogonadismN/ie/tuners/administer/at/puberty/along/w/GH/
Menstrual/irregularities/(dysmenorrhea)/
///////////Menopausal/hot/flashes/and/atrophic/vaginitis/
///////////Postmenopausal/osteoporosis/
/
Androgen/depended/prostate/cancer//
Adverse/reactions:/
Nausea,/vomiting,/and/diarrhea/
Post/menopause/bleed//
Inc/risk/of/thromboembolism/bc/inhibit/antithrombin/III/activates/factors/II,/VII,/IX,/X//
Gall/stone/formation/
Increase/risk/for/breast/cancer/and/endometrial/cancer/(not/when/progestin/is/added)/
DES:/Clear/cell/adenocarcinoma,/Incompetent/cervix/
/
Contraindications:/ER+/breast/ca/and/DVT/
Carcinoma/of/the/endometrium/or/in/those/at/high/risk/for/carcinoma/of/the/breast/
Undiagnosed/genital/bleeding,/liver/disease,/or/a/history/of/thromboembolic/disorder/
Should/be/avoided/by/heavy/smokers/
(
(
(
Antiestrogens:(Clomiphene(estrogen(receptor(antagonist((
Clomiphene/blocks/negative/feedback/to/hypothalamus/and/pituitary/
GnRH,/FSH,/and/LH/secretion/are/increased/as/a/result/of/the/block/to/the/negative/feedback/
/
Uses:/Infertility/due/to/anovulation/in/women/ep/POD/and/Obesity/
///////////Infertility/in/men/due/to/disturbance/in/spermatogenesis/
///////////Invitro/fertilization/
/
Adverse/Effects:/Hot/flashes/
/
///////Leads/to/temporary/menopause//
///////Ovarian/hyperstimulation/(enlargement)/
///////Increased/incidence/of/multiple/births!/John/and/Kate/+8/
///////Ovarian/cysts/
(
Selective(Estrogen(Receptor(Modulators:((SERMs)estrogen/like/action/in/some/places/not/all/
/
Agonist/at/bone/inhibiting/osteoporosis//
and//liver/
/
Antagonist/at/breast/reducing/risk/of/breast/ca/
Strengthens/bones/
Lowers/LDL/cholesterol/
Increases/blood/clot/risk/
Tamoxifen:///agonist/at/brain/as/well/
SE:/Endometrial/proliferation///inc/risk/for//endometrial/ca/
//////Hot/flashes//
Therapeutic/uses:/Breast/cancer/–/ER+/PR+/tumors/
//////////Preventive/agent:/5/years/–/reduces/Ca+/recurrence////////
(
Raloxifene(((Antagonist/in/breast,/endometrium/May/reduce/uterine/cancer/risk/
No/relief/for/hot/flashes/
Therapeutic/uses:in/post/menopausal//
/Osteoporosis:/Reduces/the/rate/of/bone/loss,/inc/peripheral/bone/mass/
NDecreases/the/rate/of/vertebral/fractures/
Prophylaxis/of/breast/cancer/
(
Progestin(inc(endometrial(vascularization(/
1.
Progesterone((natural)(
2.
Medroxyprogestrone/IM/good/for/3/months(
3.
Norethindrone(
4.
Norgesterol/implant/good/for/5/years(
Indications:/Contraception/depot/
NNHRT/to/lower/risk/of/cancer/
Effects:/oppose/the/effects/of/estrogen…endometrial/ca/
Androgenic/(hirsutism/and/Acne)/
Decrease/HDL/and/Increase/LDL/
Breakthrough/bleedingNabnormal/bleeding/in/btw/2/cycles//
Decrease/glucose/intolerance/
Oppose/the/carcinogenic/effects/of/estrogen//
(
Hormonal(Contraceptives:(Estrogen(and(Progestin(98%(are(on(the(combined(pill(
Mechanism$of$Action:/Feedback/inhibition/of/FSH/and/LH/(target/LH/surge,/impt/for/ovulation)/
Oral/contraceptives/are/used/for/21/or/28/days/
/21/active// 7/inactive//
Monophasic:/same/dose/in/every/tablet/of/P/and/E/
nd
Biphasic:/2/different/doses/tablets/P/inc/in/2 /½///
rd
Triphasic:/3/different/doses/tablets/P/inc/more/in/3 N/mimic/natural/cycle/of/horm/
/
Adverse/effects:/Acne/,/oily/skin,/and/weight/gain//Manage:/lower/progestin/dose/
///////Breakthrough/bleeding/
st
///////Withdrawal/bleeding/absent:/1 /rule/out/preg/then/lower/dose/
(
ProgestinTonly(pill((minipill)/!/used/in/older/women/where/fertility/is/dec,/no/off/period//
///////////Low/doses/of/progestin,/taken/daily/without/interruption/
(
Post(coital(after(sex)(contraception:(PLANNB:/2/doses/(o.75/mg/levonorgesterl/per/pill)(
Miferpristone!/Progestrone/competitive/Antagonist/
Indication:/Termination/of/pregnancy/through/day/49/
Adverse/effects:/Vaginal/bleeding/and/cramping/
Given/w/prostaglandin/to/induce/abortion//metoprostol/(PGEI)/dilates/afferent/arteriole/and/
inc/mucus/on/stomach/lining//
/
Signs(of(Hormonal(contraceptive(complications:(ACHES(
1.
Abdominal/pain/(gallbladder/disease/or/pancreatitis)/
2.
Chest/pain/(Blood/clot)/
3.
Headaches/(stroke)/
4.
Eye/problems/(Hypertension)/
5.
Severe/leg/pain/(DVT)/
/
/
/
/
/
/
/
/
/
/
Drugs(affecting(the(male(reproductive(system:(Androgens(
Testosterone(androgen(receptor(agonist(inhibits(LH(and(produces(less(testosterone(
Indications:///
/
/
Adverse/effects:/
Testicular/failure/
/
Men:/urinary/urgency,/gynecomastia/(breast/swelling)/
Orchitis/or/orchidectomy//
Women:/Hirsutism/and/hoarsenessN/masculine/
Breast/cancer//
/
Inc/LDL/dec/HDL/
Hyp/gonadism//
/
Early/epiphyseal/plate/closure//
Promotes/anabolism/in/burnt/pt/
Balls/are/small/
/
(
Oxandrolone:/Anabolic/steroid/(Anabolic:/Androgen/>1)/
Indications:/Weight/gain/and/Enhancement/of/athletic/performance/
Side/Effects:/Oxandrolone/is/a/controlled/substance/schedule/III/
/
Androgens/may/enhance/the/anticoagulant/effects/of/warfarin/
(
Drugs(used(in(management(of(BPH:(((
5/alpha/reductase/inhibitors((Finasteride/(proscar/Propecia)/
5/alpha/reductase:/Testosterone/!/dihydrotestosterone/(DHT)/!/prostate/gland/growth/
Rx:/Male/pattern/baldness/
Adverse/effects:/Decrease/libido/and/impotence/
Use/of/St/John’s/wort/may/decrease/dinasteride/levels//
Alpha/1/blockers:/Prazocin,/terazocin,/and/doxazocin:/they/also/reduce/blood/pressure/
Alternative/considerations:/Saw/palmetto:/Inhibits/DHT/from/binding/at/androgen/receptors/
Androgen/receptor/antagonists/Flutamide/and/Bicalutamide://
/
Uses:/In/conjuction/with/a/GnRH/analog/in/the/treatment/of/metastatic/prostate/cancer/
Role/of/Autonomic/nervous/system/in/sexual/response/
Parasympathetic/(Cholinergic):/Erection/
Sympathetic/(adrenergic):/Ejaculation//
/
Drugs/affecting/sexual/functioning/
1.
Antihypertensives/(beta/blockers)/
2.
Diuretics:/(thiazide/and/spironolactone)/
3.
H1/and/H2/blockers,/anticholingeric/effects/
4.
Antipsychotics/
5.
Antidepressants/
6.
Anxiolytics/
7.
Ethanol/and/barbiturates/
8.
Anabolic/steroids/
(
Drugs(used(to(treat(erectile(dysfunction(
1.
Sildenafil/(Viagra)/
2.
Tadalafil/(Cialis)/
3.
Vardenafil/(Levitra)/
They/all/are:/Phosphodiesterase/inhibitors/(PDE5),/they/inhibit/the/enzyme/that/metabolize/
cGMP,/leading/to/an/increase/in/cGMP/(Guanosine/monophosphate)/
In/the/corpus/cavernosum/enhancing/muscle/relaxation,/increasing/the/inflow/of/blood/
causing/erection/
Adverse/effects:/Headaches,/facial/flushing,/back/pain/
High/doses/may/cause/optic/neuropathy/
/
Precautions/with/PDE5/inhibitors:/
1.
Absolutely/contraindicated/with/nitroglycerin./Why?/!/Severe/hypotension/
2.
Sildanefil/has/not/effect/in/the/absence/of/sexual/stimulation/
3.
Tadalafil/has/an/onset/of/action/w/in/1/hr/but/duration/of/action/up/to/36/hrs/
4.
Use/in/women/is/under/study//
Diabetes/Pharm//Drugs/used/in/Diabetes/Mellitus/
Pancreas/
Insulin/NBetaNcells/of/islets/of/Langerhans……Triggered/by:/Inc/blood/glucose/level/
GlucagonNAlphaNcells/of/the/islets/of/Langerhans……Triggered/by:/Dec/blood/glucose/level/
Type(I,(IDDM(No/insulin(
Type(II,(NIDDM(Have/insulin/but/resistance(
<30y/old/
>40y/old/
Lean/
Obese/No/autoantibodies/
Autoantibodies/
Hyperosmolar/coma/(HHNS)/
Ketoacidosi/
Oral/hypoglycemic/
Gotta/give/insuliln/
+/N/insulin/
Diagnosis(of(diabetes(mellitus(
Symptomatic/patients://Polyurea,/polydipsia,/ketonuria//Plasma/glucose/>/200mg/dL/
Asymptomatic/patients/:/Fast/blood/glucose/>/125mg/dL/on/2/occasions/
/
Normal/glucose/
tolerance/
<110/
<140/
Impaired/glucose/
tolerance/
110N125/
140N149/
Diabetes/
Mellitus/
126/
200/
Fasting/plasma/glucose/(mg/dL)/
2hours/after/glucose/load/
(mg/dL)/
HbA1c/(%)/
<5.7/
5.7N6.4/
6.5/
When/you/answer/Hemoglobin/A1C?/!/Not/diagnosis/but/follow/up/in/diabetic/patients/
A1C:/Condensation/of/glucose/with/hemoglobin/reflects/degree/of/hyperglycemia/
Insulin/Preparations:/Remember/to/take/this/insulin/(Aspart)/as…part/of/your/meal//
/
Preparation/
Onset/
Peak/Effect/
Duration/
Rapid/acting/
Lipro/
5N15m/
1N2/hrs/
3N4/hrs/
Aspart/
Glulisine/
Short/acting/
Regular/(SC/IV)/ <30m/
2N4/hrs/
5N7/hrs/
Intermediate// NPH/
2/hrs//
4/hrs//
16/hrs/
/
Lente//
Long/acting//
Glargine/
60N90/m/
Peakless/
>24/hrs/
Detemir/
Ultralente/
The/standard/mode/of/insulin/therapy/is/subcutaneous/(SC)/injection/–bc/slow/release//
IV:/Intravenous/brings/down/rapid/DKA;/NPH:/Neutral/Protamine/Hededorn/
/
Glut/2/and/4/impt/Liver/fat/skeletal//
Note:/Insulin/glargine/and/detemir/must/be/given/as/separate/injections/
(
Continuous(Subcutaneous(Insulin(Infusion(Devices((CSII,(Insulin(pumps)(
Programmed/to/deliver/insulin/at/a/low/basal/rate//
/////and/premeal/boluses/to/control/post/prandial/glycemia/
Insulin/aspar,/lispro,/and/glulisine/all/are/specially/approved/for/pump/use/
(
Mechanism(action(of(insulin:(Insulin/binds/to/transmembrane/receptors/(/2/alpha/and/2/beta/
subunits)/alfa/subunits/and/through/a/complex/series/(Tyrosine(kinase)/of/phosphorylation/
promotes/entry/of/glucose/into/the/cell/…metabolized/by/liver/60%/and/kidney//30%(
/This/is/endogenous/exogenous/is/opposite//
Indications/of/Insulin/
1.
Diabetes/mellitus/(type/1,/2/and/gestational/diabetes)/
2.
Postpancreatectomy/diabetes/
3.
Diabetic/ketoacidosis/
4.
Hyperglycemic,/nonketotic/coma/
(
Goals(for(therapy((FBS:/90/–/120/mg/dl/
PPBS:/<150/mg/dl/
HbA1C/</7%(
(Condensation/of/glucose/w/hemoglob/reflects/the/degree/of/hyperglycemia/for/the/past/4m)/
Insulin:/0.3/–/0.5/U/kg/
2/3/given/in/AM/(2/3/as/NPH,/½/as/R)/ /
½/given/in/PM/(1/2/as/NPH,/½/as/R)/
Complications/of/Insulin/Therapy/
1.(Hypoglycemia:bc/excess/does//
Signs/of/autonomic/hyperactivity:/Sweating,/hunger,/parethesias,/palpitations,/tremor,anxiety/
Why?/Decrease/blood/glucose/trigger/epinephrine/
/
Neuroglycopenic/symptoms:/Difficulty/in/concentrating,/confusion,/weakness,/drowsiness,/
//////////////a/feeling/of/a/warmth,/dizziness,/blurred/vision,/and/loss/of/consciousness/
/
Classification://Post/prandial/after/lunch/blood/glucose/is/low/
/////Fasting/hypoglycemia/–/Low/blood/glucose/+/symptoms,/get/better/if/eat/sugar/
/
/
Drugs/used/to/treat/hypoglycemia// /////////Indication:/Insulinoma/causing/hyperinsulinism/
Glucagon/
Dextrose/
Diazoxide/…overdose:/!/Hyperglycemia/and/ketoacidosis/
/
2.(Immunepathology(of(insulin(therapy(
Insulin/allergy:/anti/insulin/IgENmediate/local/cutaneous/reactions,/angioedema,/urticarial/
Immune/insulin/resistance:/IgG/antibodies/neutralize/the/action/of/insulin/
/
3(Lipoatrophy(Atrophy/of/subcutaneous//fat/at/the/site/of/insulin/injection(
Lipohypertrophy:/Enlargement/of/subcutaneous/fat/depots/
/
(
Insulinoma:/Benign/tumor/producing/insulin.//Serum/insulin/8ug/mL/and/blood/glucose/below/
40/mg/dL./Inappropriate/high/insulin/despite/low/blood/glucose/C/peptide//and/no/Ab/
Rx:/Surgery/
/
Factitous(Hyperinsulinism((SelfNingestion/of/insulin!/exogenous/taking/not/making/develops/
Ab/and/no/C/peptide/and/no/proinsulin/(
Triad/of:/Hypoglycemia,/Antibodies,/Suppressed/plasma/C/peptide(
/
How(can(you(tell(if(it(is(insulinoma(or(factitious/
Plasma/insulin/and/insulin/glucose/ratio/elevated/in/both/condition/
Look/for/proinsulin/and/C/peptide!Only/elevated/in/insulinoma/
Why?/You/are/making/insulin/not/taking/it//
Look/for/antibodies/against/insulin/!/only/if/you’re/taking/insulin//inly/in/factitious/
How/about/if/someone/is/taking/glipizide?/insulin//C/peptide/is/inc/but/antibodies/are/absent/
bc/endogenous/insulen/secetion/an/kyoku/need/to/To/test/if/someone/is/ingesting/SulphonylN
urea:/Do/urine/sulphonylTurea/to/see/if/there/is/a/self/induced((endogenous//+/c/pepetind/+/
proinsulin/but/no/Ab)/
(
Complications(of(Diabetes(
DKA(Diabetic(ketoacidosis(Type(I(Incr/plasma/glucose,/H+,/ketones,/K+,/Dec/HCo3,/intrace/K+(
Fruity/breath/odor/of/acetone/
Here/give/insulin/drip/until/Acetone/goes/away/
In/DKA:/Blood/glucose/is/400/mg/dL/+/Ketone/bodies/
/
Precipitated/by:/Insufficient/insulin/therapy/
Infection/
Emotional/stress/
Excessive/alcohol/intake/
/
No/insulin/!/decrease/uptake/of/glucose!/hyperglycemia/
No/insulin/!/increased/lipolysis/!/Increased/free/fatty/acids/!/Ketone/bodies/!/they/
become/acidotic/(decreased/pH),/Compensate/by/blowing/out/CO2/(Kussmaul’s/respiration)//
/
How/you/treat/DKA?/
IV/insulin/(regular)/
IV/fluids,/Dextrose/
Correct/electrolytes/K+/
/
(
Hyperosmolar(coma((HHNS)(Type(II((Hyperosmolar/hyperglycemic/nonNketotic/syndrome(
MC/in/elderly/pt/of/type/2//(they/are/on/other/drugs/that/alter/th/insulin/action)/you/get/
dehydration/Severe/hyperglycemia/up/to/1000/mg/dL/without/significant/ketosis/
Precipitating/factors:/Infections,/strokes,/and/MI./Common/in/elderly/diabetics/
Diagnosis:/Blood(glucose(>(1000mg/dL,/High/serum/osmolality/(more/the320)!/blood/is/
hyperficosut/can/make/thrombosis/can/you/need/to/give/heprin,/High/BUN,/No/ketosis/
(
Chronic(complications(of(Diabetes:(BC(OF(ENDOTHELIAL(DAMAGE..(
1.
Retinopathy:/Leading/cause/of/blindness/
2.
Nephropathy/
3.
Neuropathy/
a.
Peripheral:/Numbness,/paethesia,/and/pain/
b.
Autonomic:/Gastroparesis/and/impotence/
If/glucose/is/high/!/Insulin/promotes//glucose/in/to/liver/fat/and/skeletal/M/
If/glucose/is/low/!/Counter/regulatory/hormones/to/maintain/blood/glucoise/
Glucagon/
Growth/hormone/
Cortisol/
Epinephrine/
(
Honeymoon(period((IDDM//type/2/patients:/Decrease/insulin/need(
Why?/!/Restoration/of/some/insulin/production/only/for/short/period/of/time/
(
Common(in(type(1(
Somogyi(effect(…Rebound(hyperglycemia/in/the/morning/bc/Too/much/insulin/before/bed/
time/causing/and/episode/of/hypoglycemia/in/the/middle/of/the/night/!/stimulate//release/of/
counter/regulatory/homones/glucagon/and/growth/hormone/release/!/hyperglycemia/in/the/
morning//
How/to/correct/this/you/!/Lower(insulin(befoe(bed(time/
/
Dawn(Phenomenon((Early/morning/hyperglycemia/Counter/regulatory/hormones/kicks/in/at/
night/bc/of(Reduced/tissue/sensitivity/to/insulin/between/5/am/and/8/am/(75%/type/1)/here/to/
correct?/Increase/insulin/at/bed/time//
/
How(can(you(tell(Somogyi(from(Dawn?(
Ask/them/if/they/get/up/in/the/middle/of/the/night/thirsty/and/urgent/to/pee(DM/symoptos)/
toto/o/measure/their/blood/glucose/at/night/
!/If/it/is/low/–/it/is/Somogyi((Rebound(hyperglycemia)/
!/If/it/is/high/–/It/is/Dawn(phenomenon(–(No(hypoglycemia!(
/