What Is Androgen Therapy?

Sex hormones are mainly secreted by the gonads (ovaries, testes), including estrogen, progesterone and androgens, all of which are steroid hormones. The ovaries mainly synthesize and secrete the first two female hormones and a small amount of androgens. The testes mainly synthesize and secrete androgens also produce a small amount of estrogen. In addition, the adrenal cortex and the placenta during pregnancy can also produce sex hormones. Sex hormones mainly act on the reproductive system, promote the development, maturation, and maintain their physiological functions of reproductive organs and parasexual characteristics. They also affect other systems of the body, such as bones, metabolism, cardiovascular, and skin.

Sex hormone therapy

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Gonadal hormones are directly affected by

Estrogen

The clinical application is very extensive.

The preparations are classified into steroid (steroid) estrogen and non-steroid (steroid) estrogen by chemical structure. Steroid estrogen such as estradiol benzoate, potent, most commonly used as an intramuscular injection; estradiol dipropionate, for intramuscular injection, slow absorption after injection; estradiol valerate, long acting, intramuscular injection; ethinyl estradiol Diol, abbreviated as ethinylestradiol (EE), is potent (approximately 10-20 times greater than diethylstilbestrol) and is administered orally; ethinylestradiol cyclopentyl ether, also known as ethinylestradiol, long-acting, orally; nilestriol, and Named ethinylestradiol, which is a derivative of estriol, is orally administered for a long period of time; estriol, which is weakly active, is available in three formulations: oral, intramuscular, and topical. Non-steroidal estradiol preparations: Diethylstilbestrol (DES), also known as acetol, is the most commonly used oral agent. Hexestrol is also known as Yushen, and its efficacy is 1/5 of DES. The chemical structural formula of estrogen drugs is shown in Figure 1.

Clinical applications are used in the following areas:

Adolescent dysfunction

Uterine bleeding: use estrogen to stop bleeding and adjust the cycle. First use a large dose of diethylstilbestrol, ethinylestradiol and estradiol benzoate to promote rapid proliferation and repair of the endometrium to achieve hemostasis. Decrease the dose after hemostasis, continue to use for 15-20 days, to maintain the endometrium does not fall off, so as to adjust the cycle, withdrawal bleeding 2 to 3 days after stopping. It must be noted that the drug cannot be stopped immediately or the dose is reduced too much after the hemostasis, so as to avoid repeated bleeding due to withdrawal bleeding.

Amenorrhea: People with congenital ovarian hypoplasia use estrogen instead of treatment, which can promote breast, external genital development, axillary and pubic hair growth, endometrial hyperplasia and shedding, which are of physiological and psychological significance and need long-term use. Secondary amenorrhea caused by hypothalamic-pituitary dysfunction is treated with artificial cycles. To simulate the normal menstrual cycle hormone level changes, estrogen was given for 20 days, and progestin was added for 5 days to form a withdrawal bleeding once a month. Generally 3 cycles are 1 course of treatment. Low-dose estrogen can stimulate pituitary function, increase its sensitivity (positive feedback), and help recover the menstrual cycle.

Menopausal syndrome: Women's ovarian function gradually declines to menopause, and finally menopause. Artificial menopause occurs after bilateral ovaries are surgically removed. Postmenopausal estrogen reduction, increased pituitary gonadotropin secretion, can produce a series of symptoms of autonomic nervous system dysfunction such as hot flashes, dysentery and so on. Symptoms can be significantly improved after estrogen application. Estriol, diethylstilbestrol or ethinylestradiol are usually used in a dosage based on the minimum dose that can control symptoms without causing vaginal bleeding. The medication was stopped for 20 days for 1 week. If long-term use is required, progestin should be added to prevent endometrial cancer caused by long-term acceptance of a single estrogen.

senile vaginitis, with the decrease of estrogen after menopause, the vaginal epithelium shrinks, the resistance decreases, and infection is prone to occur. Estrogen can promote vaginal epithelial hyperplasia and increase local resistance. Can be administered in small doses of estrogen, orally or topically. Estriol selectively acts on the vaginal epithelium, and has a weak effect on the endometrium, and generally does not cause withdrawal bleeding. Osteoporosis: Estrogen has the effect of reducing bone absorption and protecting bones, and has the effect of preventing osteoporosis in postmenopausal women. But it must be started early for long-term use to be effective. For diagnosed osteoporosis, estrogen treatment can only reduce bone resorption, maintain relative bone mass, and reduce symptoms without compensating for lost bone mass.

Infertility: Those with poor uterine growth or cervical mucus that are unfavorable for sperm penetration, use a small amount of estrogen to promote uterine development and make cervical mucus thin to facilitate sperm passing through the cervix

Prostate cancer: Large doses of estrogen can inhibit the secretion of pituitary gonadotropin, leading to testicular atrophy and reduced androgen secretion. At the same time, estrogen also has an anti-androgen effect, so it can be used to treat prostate cancer.

Breast Cancer: The mechanism of estrogen therapy for breast cancer is unknown. Premenopausal breast cancer patients with estrogen can develop aggravated tumors, so it is contraindicated; postmenopausal (more than 5 years) advanced breast cancer or postoperative recurrence of large doses of estrogen can obtain a 30-40% remission rate.

Acne: It is more common in adolescence. It is caused by sebaceous gland blockage and secondary infection caused by androgen stimulation of sebaceous glands, so it can be treated with estrogen. The use of estrogen in men can cause male breast development, and testicular function is inhibited, so it should be used with caution.

Side effects The most common side effects of oral estrogen are nausea, vomiting, and dizziness. When there are side effects, intramuscular injection can be used instead. Long-term use of estrogen alone increases the risk of endometrial cancer, and its incidence is related to the dose and time of medication. The literature reports that for patients who have been using estrogen replacement therapy for a long time, adding 10 to 14 days of progestin every month can reduce the incidence of endometrial cancer to the same or even lower than the general population. Whether taking estrogen for a long time increases the incidence of breast cancer is not certain, and the effect of reducing the incidence of breast cancer is not seen with progestin. Estrogen has a procoagulant effect, and patients with thrombophlebitis are contraindicated. During the estrogen replacement treatment, the cholesterol in the bile increases, the bile acid concentration decreases, and gallstones are easily formed. Estrogen has the effect of stimulating the smooth muscle of the uterus, and can cause the development of uterine fibroids at high doses. When postmenopausal women are treated with estrogen, if there is abnormal uterine bleeding, endometrial adenocarcinoma must be ruled out. It is contraindicated for pregnant women. Taking a large amount of diethylstilbestrol in early pregnancy has the potential to cause vaginal cancer in baby girls to puberty. Estrogen retains water and sodium, which can cause edema and weight gain. Large doses of estrogen can damage liver function and occasionally cause jaundice. Estrogen promotes epiphyseal closure and avoids long-term or large-scale use in minors to avoid affecting height growth.

Progesterone

It is also commonly used clinically to treat diseases and contraception.

The preparations are mostly artificial: Progesterone, that is, progesterone, can be extracted from the ovarian corpus luteum (natural progesterone), and most of them are artificially synthesized. The oral titer is low, and its injection is used clinically. 17- Hydroxyprogesterone derivatives, such as progesterone hexanoate, are long-acting and have a potency twice as high as progesterone; megestrol acetate, referred to as mesoprogesterone, with the trade name angong progesterone, has a short oral effect, and the injection is Long-acting; megestrol acetate is referred to as megestrol, a brand name Fu Ning Tablets, taken orally; chlordrogesterone is highly effective and has a weak anti-androgenic effect. 19-desmethyltestosterone derivatives, such as norethisterone, a brand of fukang tablets, are highly effective, oral, with androgenic and anti-estrogenic effects; norethisterone, which has both androgenic effects; 18-norethisterone , Progesterone has the strongest effect, but has androgenic effect. The chemical structural formulas of various progestin drugs are shown in Figure 2.

Clinical application is used in the following areas: functional uterine bleeding: use progestin to stop bleeding and regulate the cycle. Progesterone can transform the proliferative or proliferative endometrium into the secretory phase, delay the withdrawal bleeding caused by estrogen, stop the breakthrough bleeding caused by insufficient progesterone, and achieve hemostasis. After the hemostasis, maintain the amount for 2 to 3 weeks. Withdrawal bleeding occurred 2 to 7 days after drug withdrawal, and the endometrium fell off completely and quickly, which is also called "drug curettage". Thereafter, the drug was administered on a periodic basis, and the medication was started for 5 to 7 days on the 20th day of menstruation. Luteal dysfunction is insufficient: Progestin is used for 5-7 days on the 20th day after menstrual cramps to improve the endometrial secretion function. Atrophy of the corpus luteum: Premenstrual estrogen and progesterone cannot fall rapidly, resulting in irregular shedding of the endometrium, prolonging the menstrual period and increasing blood volume. On the 16th to 21st days after menstrual cramps, progestin was continuously used for 5 to 10 days. After the drug was stopped, the endometrium completely fell off and the menstrual period shortened. Amenorrhea: secondary amenorrhea with a certain level of estrogen in the body, intramuscular injection of progesterone 10mg, once a day for 5 days, withdrawal bleeding occurred after discontinuation. Threatened abortion: In the past, progesterone was commonly used to inhibit uterine muscle contraction and promote strong endometrial secretion to facilitate embryo growth. However, it is not advisable to use any sex hormone to protect the fetus. Progesterone is useful for threatened abortion caused by insufficient corpus luteum function, and is of little value for other causes of abortion. Endometriosis: the use of high-efficiency progesterone to cause amenorrhea similar to pregnancy, continuous medication for 3 to 9 months (also known as pseudopregnancy therapy), causing ectopic endometrium to produce decidualization and atrophy Then it shrinks or disappears. The disadvantage is that the ovulation resumes later after the drug is stopped (delayed 6 to 12 months). Mild patients sometimes use progestin cycle medication to relieve symptoms and prevent disease progression. Endometrial cancer: Progestins act on cancer cells, inhibit tumor growth, and increase the sensitivity of cancer cells to radiation therapy. Good effect on highly differentiated adenocarcinoma. Breast cancer: 20 to 30% of tumors have regressed significantly after administration, and the mechanism is unknown, which may be related to the effect of progesterone on the target organs against estrogen. Effective drug for advanced breast cancer. Prostatic hypertrophy and prostate cancer: Progesterone inhibits FSH secretion from the anterior pituitary gland, reduces testosterone secretion, and also has a direct effect on prostate epithelial cells, which can be used for prostate hypertrophy and cancer. Use androgen-free progesterone preparations.

Side effects can be divided into five aspects: Occasionally mild depression, dizziness, breast swelling, tiredness, and lethargy. Weight gain is caused by water retention and protein synthesis of some progesterone residues. Nortestosterone derivatives can make the endometrium atrophy. It should be used with caution for rare menstrual periods, and occasionally long-term amenorrhea. The use of synthetic progesterone in early pregnancy can cause VACTERL syndrome (spine, heart, trachea, esophagus, kidney, limb deformity) in the fetus, with cardiac malformations most common. Norethindrone has an androgenic effect, which can virilize female fetuses. Androgenic progesterone can cause hairy and acne. Long-term application of large doses, especially norethisterone, can increase GPT, and can naturally decrease after stopping the drug. Those with a history of hepatitis should use it with caution. Decrease the serum high-density lipoprotein concentration and increase the risk of arteriosclerosis. This change is related to the dose. Long-term users should pay attention to changes in blood lipids.

Androgens

It is used clinically to promote the maturity of male sexual organs and secondary sexual characteristics, fight against androgens, inhibit endometrial growth, and promote protein synthesis and bone formation. Preparations Testosterone (testosterone) is a natural androgen, and is mostly synthetic. There are two types of testosterone derivatives and protein anabolic hormones: Testosterone derivatives, such as testosterone propionate, testosterone phenylacetate is slightly stronger than testosterone propionate; methyltestosterone is 1/5 of testosterone propionate. Protein anabolic hormones: There are some testosterone derivatives whose androgenic effect is greatly weakened, while protein assimilation remains or increases, also known as anabolic steroid hormones, abbreviated asabolic hormones. These hormones promote protein synthesis and reduce catabolism. Build muscles and gain weight. It is prohibited for athletes to take anabolic hormones. Such drugs are Nandrolone phenylpropionate (nortestosterone phenylpropionate, dolproline), Nandrolone decanoate, (long-acting dolproline), dehydromethyl testosterone (Dianabol), Stanozolol (Pyridoxine) Zometholone) and trometholone (hydroxymethine). The chemical structural formula of androgens is shown in Figure 3. The chemical structural formula of androgens. Clinical application Menopausal uterine bleeding, androgens have anti-estrogen effects, increase uterine muscle and vascular smooth muscle tension, reduce pelvic congestion, and testosterone propionate can reduce bleeding, but its hemostatic effect is poor. Hemorrhage (including testosterone propionate, estradiol benzoate, and progesterone) has a better hemostatic effect during major bleeding; for menopause, more testosterone propionate and progesterone cycles can be used to reduce the dose and control the cycle . Uterine fibroids and endometriosis, methyltestosterone can counteract the effects of estrogen, control the development of fibroids, reduce bleeding and alleviate dysmenorrhea of endometriosis, every 20 days after menstruation. Low female libido, methyltestosterone can enhance female libido. Testicular and testicular-like (testicular dysfunction), androgen replacement therapy is used to promote the development, maturation and maintenance of sexual organs and secondary sexual characteristics. Menopausal syndrome, testicular function gradually declines with age, testosterone secretion decreases, causing a series of symptoms: decreased libido, decreased sexual function, insomnia, irritability, and sometimes hot flashes, etc., androgen replacement therapy can be used. It can relieve the patients with advanced breast cancer or breast cancer with bone metastases. Physical weakness, anemia, and wasting diseases. Assimilation hormones promote protein synthesis and red blood cell production, which can enhance physical fitness and treat anemia.

There are four aspects of side effects: Male virilization. Acne, hairy, clitoral hypertrophy, and rough voice appeared. The symptoms disappeared soon after stopping the medicine. Therefore, androgen should not be used for a long time, and the monthly dosage should not exceed 300mg. Methyltestosterone can cause hepatic jaundice, and it is best to use it intermittently, liver and kidney dysfunction and pregnant women should not use it. Adolescent girls should not use it because it can accelerate the callus healing and interfere with the function of the normal hypothalamus-pituitary-ovarian axis. Males are treated with androgen for a long time, gonadotropin secretion is suppressed, and impotence and azoospermia can occur.

Antihormonal drugs

This group of drugs has strong receptor affinity, binds to specific hormone receptors at the target tissue, and competes with corresponding sex hormones, thus showing its resistance to hormones. Non-steroidal compounds synthesized by anti-estrogen drugs can reduce the specific absorption of estrogen in various tissues in the body. Chlorophenamine, trade name clomiphene (Shu Jingfen), has a strong anti-estrogenic effect, can relieve the inhibition of estradiol on the hypothalamus-pituitary-gonad, promote the secretion of gonadotropins from the anterior pituitary gland, and induce ovulation. Testosterone secretion also increased. It is widely used clinically to induce ovulation to treat infertility, irregular menstruation (such as anovulatory functional uterine bleeding, polycystic ovary, etc.), and also used for fibrocystic breast disease and advanced breast cancer (Figure 4 Chemical Structure). Tamoxifen, trade name tamoxifen, has a significant inhibitory effect on estrogen-related tumors such as advanced breast cancer and endometrial cancer, and plays a certain relief role. Premenopausal advanced breast cancer can replace ovariectomy as the preferred treatment. Can also be applied to menopausal patients. It can also treat endometriosis, induce ovulation, and directly and indirectly act on the testes to stimulate spermatogenesis, so it can treat sperm reduction. These drugs have few side effects, and occasionally cause nausea and vomiting. Mild white blood cells, thrombocytopenia, and irregular bleeding were occasionally seen after tamoxifen (Figure 5 chemical structure of tamoxifen). Anti-androgens block the effects of androgens on target tissues (including testes, paragonads, skin and its appendages, bones, etc.), affecting sexual function, various metabolic processes and embryo differentiation. It is clinically used to treat prostatic hypertrophy, prostate cancer, acne seborrhea, female hirsutism, male baldness, hypersexuality, and precocious puberty. Cycloprogesterone acetate (Septorone acetate) is a potent antiandrogenic drug, a progesterone derivative, and also has strong progestin activity. Lodesgestrol is a potent progestin and its antiandrogenic effect is weak. Flutamide is a non-steroidal anti-androgenic drug. It has no progesterone activity and does not inhibit the secretion of gonadal hormones. It is called "pure" anti-androgen. Widely used in clinical applications is Supteron acetate.

Antiprogestin drugs

New drugs from the 1980s. Mifepristone (Mife-pristone), also known as Mifegyne RU486, RU38486 (synthesized by the French company Rous-sel-Uolaf) ZK95890, mainly acts on the progesterone receptor (PR) of the endometrium (decidua). The PR that competes with the endometrium (decidua) acts as an antiprogestin, and can also inhibit the production of LH and the gonads at the level of the hypothalamus and pituitary to reduce estrogen and progesterone. It is mainly used to prevent early pregnancy. It is a new type of contraceptive, and it has been reported to be effective in terminating early ectopic pregnancy. Trienolone (Gestrinone R2323) has a strong antiprogestin effect, and may reduce the secretion of pituitary gonadotropin (LH, FSH) and ovarian estrogen and progesterone by inhibiting GnRH of the hypothalamus, thereby making the uterus Endometrial atrophy, clinical trials for the treatment of endometriosis, initially achieved good results.

Gonadotropin (GnH) A hormone secreted by the pituitary gland, including follicle stimulating hormone (FSH) and luteinizing hormone (LH). There are three types of gonadotrophins:

(human) chorionic gonadotropin (hCG). It is the oldest gonadotropin in clinical use and is extracted from the urine of pregnant women. Injections, 500, 1000 International Units (IU) each, intramuscularly. Has a similar effect to LH. Can promote the development of near-mature follicle ovulation, simulating the role of LH peak in the middle menstruation. Ovulation can be induced by administering a large dose of hCG when the follicles are near maturity, which can be used to treat ovulation dysfunction infertility, and to stimulate superovulation during in vitro fertilization. Depending on the situation, it can be used alone or in combination with other ovulation-promoting drugs such as chlorophenamine and menopausal gonadotropins. Continued use of hCG after ovulation can promote corpus luteum function and make the corpus luteum secrete enough progesterone. It is clinically used to treat corpus luteum insufficiency or habitual abortion caused by it. For men, hCG can promote the function of seminiferous tubules and interstitial cells, increase androgen production, promote testicular decline, and is used to treat male sexual dysfunction and adolescent cryptorchidism.

Human menopausal gonadotropin (hMG). Extracted from the urine of menopausal women. Each of them contains 75 international units of FSH and LH. They were injected intramuscularly and were successfully produced in China in 1986. It has the effect of promoting follicle maturity and inducing ovulation. Indications are anovulation simply due to hypohypophyseal hypogonadism; ovulation dysfunction infertility is not treated by other ovulation-stimulating drugs; used for in vitro fertilization can stimulate superovulation. Depending on the situation, it can be used alone or in combination with hCG. During the treatment, the follicular development must be monitored. With the help of cervical mucus examination, blood estradiol, LH measurement, and B-mode ultrasound test results, the follicular development can be comprehensively judged in order to adjust the dose and time of hMG medication and determine the time of hCG administration. Different degrees of ovarian hyperstimulation syndrome can occur during treatment, manifested as enlarged ovaries, severe cases of ascites, pleural effusion, oliguria, and electrolyte disorders, which must be closely observed and treated in time; multiple pregnancy due to hMG allows multiple follicles to develop simultaneously , Ovulation, pregnancy.

Follicle-stimulating hormone (FSH). FSH concentrated preparations purified from gonadotropins, each containing FSH75IU (LH <1IU), was a new drug in 1980. FSH alone or in combination with hMG at the beginning of the cycle can increase the FSH / LH ratio during early follicular development, which is more physiologically desirable than using hMG containing equal amounts of FSH and LH. It is clinically used for in vitro fertilization to stimulate superovulation with good results.

Luteinizing hormone releasing hormone

(LHRH) is secreted by the hypothalamus. Purified from the hypothalamus of pigs in 1971, and artificially synthesized in China in 1973.

Commonly used preparations are artificial products: Luteinizing hormone-releasing hormone, LHRH (10 peptides), 50 g each, intramuscularly or intravenously; LHRH (9 peptides), LHRH analogue agonists, whose biological activity is about It is about 15 times more effective than natural 10 peptides. The characteristics of LHRH and its analogue agonists can vary depending on the mode of administration and the length of treatment, and it can regulate the function of the hypothalamus-pituitary-gonadal axis in both directions. The method of simulating the physiological release of endogenous LHRH, pulsed intermittent administration, can activate the pituitary-gonadal axis function, can induce ovulation and spermatogenesis; continuous administration of large doses of LHRH or long-term, non-pulsed administration of LHRH agonists produces reverse Regulation and suppression, but the pituitary-gonadal axis function can return to normal after stopping the drug. Clinical use of this reversible "pituitary pituitary" or "drug ovariectomy" to treat a variety of hormone-related diseases. Application of this drug requires different methods of administration according to different therapeutic purposes: Inducing ovulation and spermatogenesis, LHRH can be administered intravenously or subcutaneously using an automatic micropulse injection pump to activate pituitary-gonadal function. It is used to treat hypothalamic amenorrhea or anovulation, polycystic ovary syndrome, unexplained infertility, and luteal insufficiency. Its advantages are no side effects and no ovarian hyperstimulation syndrome. Rare complications are phlebitis and subcutaneous hematoma. Treatment of hypothalamic sexual dysfunction or oligozoospermia in men has also achieved significant results. Inhibition of pituitary-gonad axis function by long-term administration of LHRH agonists to treat hormone-related diseases. Is a new field of application. For endometriosis, the secretion of ovarian sex hormones is inhibited after administration, causing endometrial atrophy, and the treatment period is 6 months. The side effect is that menopausal symptoms such as vaginal dryness, hot flashes, caused by low estrogen. For uterine fibroids, long-term application of LHRH agonists can make fibroids shrink and relieve symptoms. The course of treatment is 6 months, and fibroids can grow again after stopping treatment. Also used for true precocious puberty, breast cancer, prostate cancer and so on. LHRH analog antagonists can inhibit the function of the pituitary-gonad axis, and related research is still in the experimental research stage.