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Chapter 28: Estrogens, Progestins, Androgens, and Contraception

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A 30-year-old woman is being started on birth control pills for the first time. She has a history of migraine headaches with aura. Therapy with which one of the following contraceptive formulations is contraindicated in this patient?

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a. Levonorgestrel

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b. Mifepristone

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c. Norethindrone

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d. Ethinyl estradiol/norethindrone

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e. Ulipristal

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Answer is d. The combination (estrogen/progestin) contraceptives are contraindicated in women with a history of thromboembolic disease, cerebrovascular disease, migraine headaches with aura, estrogen-dependent cancer, impaired hepatic function or active liver disease, undiagnosed uterine bleeding, and suspected pregnancy. Levonorgestrel and ulipristal are used as emergency contraception and mifepristone is used to terminate pregnancy. Norethindrone is a progestin-only oral contraceptive. While slightly less effective than the combination estrogen/progestin formulations, norethindrone provides an alternative in settings where estrogen-containing formulations are contraindicated.

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A 56-year-old woman with an intact uterus is being treated with hormone replacement therapy with a product that contains an estrogen/progestin combination (estradiol/norethindrone). The progestin is added to

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a. decrease the risk of endometrial cancer.

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b. decrease the incidence of breast cancer.

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c. increase the effectiveness in treating vasomotor symptoms.

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d. decrease the risk of coronary heart disease.

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e. decrease the risk of cognitive impairment.

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Answer is a. In postmenopausal women with an intact uterus, a progestin is included in hormone replacement therapy to prevent endometrial cancer. The structural features of various progestins are shown in Figure 28-7.

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Figure 28-7. Structural features of various progestins.

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A 25-year-old woman is being treated with clomiphene for fertility. Clomiphene acts by

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a. blocking estrogen effects on the uterus.

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b. increasing FSH concentrations.

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c. blocking progesterone effects on the ovary.

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d. decreasing LH concentrations.

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e. increasing progesterone secretion by the ovary.

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Answer is b. Clomiphene is a potent antiestrogen that primarily is used for treatment of anovulation in the setting of an intact hypothalamic-pituitary axis and adequate estrogen production. Clomiphene acts by inhibiting the negative feedback effects of estrogen at hypothalamic-pituitary levels, increasing follicular-stimulating hormone (FSH) concentrations and thereby enhancing follicular maturation (see Figure 28-2).

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Figure 28-2. Neuroendocrine control of gonadotropin ...

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