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Hormone replacement therapy does not have any benefit Estrogen or combined hormonal therapy has no benefit
What is the risk of breast cancer when using unopposed estrogen therapy or combined estrogen-progestin HRT
In the WHI unopposed estrogen trial, there is no increase in risk of breast cancer in 10,000 women who had a hysterectomy In the combined estrogen-progestin group, there was a significant increase in the risk of breast cancer The presence of breast cancer was seen in year 3 in women
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7: Reproductive Endocrinology and Infertility
who had previously used menopausal hormones and in year 4 who had no history of previous use What are the relative risks of endometrial cancer when using unopposed estrogen therapy versus combined estrogenprogestin hormone therapy Treatment with estrogen alone greatly increases the risk of endometrial hyperplasia and cancer Adding a progestin diminishes this excess risk of endometrial hyperplasia and carcinoma Women who have abnormal vaginal bleeding History of breast cancer History of coronary heart disease (CHD) History of estrogen-dependent neoplasia History of DVTs or thromboembolic event History of liver dysfunction/disease What are complications of estrogen replacement therapy Endometrial cancer Breast cancer Thromboembolic disease Stroke Uterine bleeding Gallbladder disease
When is estrogen replacement therapy (ERT)/hormone replacement therapy (HRT) contraindicated
Hirsutism, Virilization, and Polycystic Ovarian Syndrome
HIRSUTISM AND VIRILIZATION
What is hirsutism Excessive growth of androgendependent hair (eg, on the upper lip, chest, chin) Excessive androgen-induced changes in addition to hirsutism These include clitoromegaly, voice
What is virilization
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Section II: Topics in Gynecology
deepening, increasing muscle mass, and other masculinizing signs What is hypertrichosis It is a rare disease that refers to diffusely increased androgenindependent fine body hair, usually caused by drugs or systemic illnesses It does not represent hirsutism Hirsutism manifests with increased midline hair on the upper lip, chin, ear, cheeks, lower abdomen, chest, back, and upper arms Amenorrhea is seen in severe cases Virilization is excess hair and additional characteristics such as deepening of the voice, acne, breast atrophy, clitoromegaly, balding, and increased strength Testosterone and dehydroepiandrosterone sulfate (DHEAS) Ovary: testosterone Adrenal gland: DHEAS 17OH progesterone is a precursor to the biosynthesis of cortisol and can be converted peripherally into androgens if found in excess Polycystic ovarian syndrome (PCOS) Congenital adrenal hyperplasia (CAH; 21-hydroxylase deficiency) Androgen-secreting ovarian tumors (Sertoli-Leydig or granulosa-theca tumors) Adrenal tumors Cushing syndrome Exogenous androgens (danazol) Hyperprolactinemia Other rare disorders (hyperthecosis)
How does the clinical presentation of hirsutism differ from that of virilization
Which androgens cause and are elevated in hirsutism What two organs may be involved in hirsutism and what steroid does each mainly secrete What is the role of 17OH progesterone in the development of hirsutism
What is the most common disorder that causes hirsutism What other underlying diseases may cause hirsutism
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7: Reproductive Endocrinology and Infertility
What is idiopathic hirsutism
It is a diagnosis given to women with hirsutism without adrenal or ovarian dysfunction, normal serum androgen concentrations, normal menstrual cycles, and no other identifiable cause of their hirsutism There is often a positive family history Ovarian tumor: pelvic mass, sudden onset of amenorrhea, virilization PCOS: obesity, acne, long history of irregular menses, slow onset of hirsutism beginning at puberty, acanthosis nigricans Theca-lutein cysts: hirsutism develops during pregnancy CAH: gradual onset of anovulation, positive family history Adrenal tumor: rapid onset, virilization, abdominal-flank mass Cushing syndrome: moon facies, buffalo hump, centripetal obesity, striae, extremity wasting Hyperprolactinemia: galactorrhea or visual changes with menstrual irregularities
How may the presenting signs and symptoms of a patient help specify the disorder causing hirsutism
What laboratory studies assist in the diagnosis of the etiology of hirsutism
Testosterone >200 ng/mL androgen-secreting ovarian tumor DHEAS >700 ug/dL androgensecreting adrenal tumor 17 -hydroxyprogesterone > 200 ng/dL 21-hydroxylase deficiency LH:FSH 3 PCOS Prolactin > 200 g/dL prolactinoma 24-hour urinary free cortisol > 100 ng/24 h Cushing syndrome
What imaging studies are warranted
Pelvic ultrasound may reveal polycystic ovaries or ovarian tumors/cysts CT/MRI of the abdomen to look for an adrenal mass when DHEAS levels are elevated
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Section II: Topics in Gynecology
How is hirsutism generally treated
Treat the underlying disorder The most common medications are oral contraceptives (OCPs), GnRH analogs, and antiandrogens (first-line spironolactone, second-line flutamide, finasteride) Ovarian tumor: surgical removal PCOS: combination OCPs CAH: continuous corticosteroid replacement Adrenal tumor: surgical removal Idiopathic hirsutism: spironolactone
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