Hormone Replacement Therapy

Hormone Replacement Therapy… and other options
By:Marc Childress, MD


Risks vs. Benefits in a post-WHI world
* Cancer Risk
* Osteoporosis
* Dementia
* Vasomotor Symptoms
* Urogenital Symptoms
* Cardiovascular Disease

Breast Cancer
* Mixed Results
* Excess risk approx ½ of anticipated
* Question of prognosis, timeframe of concern

Gratuitous Perspective Slide
* Increased risk of breast CA with 10% weight gain (2 add’l cases per 1000 pt-years)
* Increased risk of breast CA with combined tx (0.8 add’l cases per 1000 pt-years)

Endometrial Cancer
* Known increase in risk with unopposed estrogen
* WHI showed no signif risk of CA with combined tx

Ovarian Cancer
* No overt correlation b/w combined HRT and ovarian CA risk
* There IS a signif risk reduction associated with OCPs

Colorectal Cancer
* Signif Risk Reduction of Colon CA with combined Est/Pro
* While less cases, trend toward worse prognosis (nodal spread)
* No risk reduction observed with estrogen alone

Osteoporosis
* Well established
* Risk reduced at hip, vertebrae, and wrist over placebo
* Similar numbers for estrogen alone vs combined tx.

Dementia
* Presumed correlation with long-term estrogen and cognitive fxn
* WHIMS (memory study)

Vasomotor Symptoms
* Signif Reduction in hot flashes
* Mod improvement in sleep
* Well-known and unchanged

Urogenital Symptoms
* Can preclude occurrence of atrophic vaginitis
* Thought to prevent urinary incontinence, contradicted by WHI and HERS

Cardiovascular Disease
* Counter to previous belief, very small increase in risk of CV events with combined tx
* Estrogen alone did not show increase in risk of CV events,
* Stroke
* Venous Thromboembolism

* Which one of the following would be accurate advice regarding these risks and benefits?
* The incidence of stroke is decreased
* The incidence of myocardial infarction is decreased
* The incidence of pulmonary embolism is decreased
* The risk of breast cancer is increased
* The incidence of colorectal cancer is increased

Overview
* Current indications (brief? Tx)
o Vasomotor sxs
o Sleep disturbance
o Urogenital changes
* Additional benefits
o Osteoporosis prevention
* Risks include
o Increase in ischemic stroke
o Increase in DVT, PE
o Mild increase in breast CA risk for combined tx
o Increase in inconclusive mammograms
o Increase in GB dz with combined tx

Osteoporosis
Vasomotor Symptoms
* Pharmacologic Therapies
Vasomotor Symptoms
* Pharmacologic Therapies
Herbal Options
Vasomotor Symptoms
* Herbal/Complementary Compounds
Vasomotor Symptoms
* Not Helpful
Urogenital Symptoms

Hormone Replacement Therapy.ppt

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Thyroid Disease Facts

Thyroid Disease Facts
By:Jeffrey Medland
Lt Col, USAF, MC, SFS
Chief, Endocrinology
MGMC, Andrews AFB, MD
Capital Conference-June 2007

Outline
* Thyroid Testing
* Hypothyroidism
o Causes
o Signs/symptoms
o Treatment
* Hyperthyroidism
o Causes
o Signs/symptoms
o Treatment
* Thyroid Nodules/ Cancer
* Thyroid Disease and Pregnancy
o Hypothyroidism
o Hyperthyroidism (Hyperemesis Gravidarum, Graves’)
o Thyroiditis
* Factors affecting Thyroid function, LT4

Thyroid
Colloid
Apical Membrane
Basal Membrane
Thyroid Peroxidase (TPO)
“Iodination Reaction”
“Coupling Reaction”

Thyroid Testing
* TSH
o Best test for screening for thyroid dysfunction!
o Log/linear response w/ FT4
+ A 2-fold change in FT4 produces a 100-fold change in TSH
o Not specific for a particular thyroid disease.
+ Don’t use TSH alone for diagnosis!
o Also useful in
+ Assessing LT4 tx in 1° hypothyroidism
+ Monitoring TSH-suppressive tx in thyroid Ca
* FT4
o Testing methods:
+ Equilibrium dialysis
+ Analog assays
o Abnormal TSH check this next
o Indications:
+ In conjunction w/ TSH for diagnosing hyperthyroidism or hypothyroidism.
+ Monitoring LT4 replacement in central hypothyroidism (TSH not helpful)
+ Assessing response to tx following 131-RAIA (Graves, toxic nodules)
+ Monitoring ATD tx in pregnant females
* FT3
o Abnormal TSH + normal FT4, then check this (T3 Thyrotoxicosis)

Pituitary Hypothyroidism
Subclinical Hyperthyroidism, Autonomous nodules
Thyrotoxicosis, Thyroiditis (stage 1)
Pituitary Hyperthyroidism
Subclinical Hypothyroidism
Primary Hypothyroidism, Thyroiditis (stage 3)
Clinical Status
FT4
Overview of Thyroid Function Tests
* Thyroid Antibodies (TPO, Tg, TSI, TRAb)
* Thyroglobulin (Tg)
* Radioactive Iodine Uptake and Scan (RAIU/Scan)
* Tc99m-Pertechnetate Scan
* Fine Needle Aspiration (FNA)
* Ultrasound
* Calcitonin

Hypothyroidism
Thyroiditis
Hypothyroidism (Treatment)
Hypothyroidism (treatment in general)
Indications for LT4 replacement
Hypothyroidism + surgery
Hypothyroidism + elderly
Combined LT4/LT3 tx
Hyperthyroid Eye Disease
Does131-RAIA worse ophthalmopathy?
Graves’ Dermopathy Thyroid Dermopathy
Thyroid Acropachy
RAIU/Scan
Increased RAIU
Decreased RAIU
Surgery (sub-total thyroidectomy)
Apathetic Hyperthyroidism
Thyroid Storm
Subclinical Hyperthyroidism
Thyroid Nodules
Red Flags concerning for Cancer
FNA Results:
Thyroid Nodules “Mimickers”
Thyroid Cancer
MTC
Thyroid Disease in Pregnancy
Four factors alter thyroid function in pregnancy
1) Transient ↑ in hCG, during the 1st trimester can stimulate the TSH-R
2) E2-induced ↑ in TBG during the 1st trimester, which is sustained during pregnancy.
3) Alterations in immune function leading to onset, exacerbation, or amelioration of an underlying autoimmune thyroid disease.
4) urinary iodide excretion, which can cause impaired thyroid hormone production in areas of marginal iodine deficiency (<50 µg/d).
Known Hypothyroidism already on LT4
Stage 1 to 4
Hyperemesis Gravidarum (HG)
Hyperemesis Gravidarum vs. Graves’
Causes of Increased LT4 requirement
Drugs Affecting Thyroid Function
Somatostatin, Glucocorticoids
Dopamine
Amiodarone Effect on Thyroid Function
Amiodarone and the Thyroid
Iodine Effect
Direct Toxic Effect
* Thyroiditis (AIT type 2)
“Innocent Changes”
Jod-Basedow phenomenon (Historical)
* Definition- Hyperthyroidism induced by excess Iodine.
* Coindet (French physician) in 1821 published his cases about Hyperthyroidism.
* In the English speaking world this became known as Graves’ disease (1835), and in the German speaking world as von Basedow’s disease (1840).
* Coindet’s cases of hyperthyroidism were actually Iodine-induced, hence it came to be known as the Iodine-Basedow phenom.
* Jod is German for Iodine, hence the Jod-Basedow phenom!
* Coindet was deprived of credit for not only describing Hyper- thyroidism, but also the variant of hyperthyroidism caused by excess Iodine
* The credit was given to Dr “Jod” who never existed!

Conditions affecting Thyroid Function
Autoimmune Polyglandular Syndromes 2
Hypokalemic Periodic Paralysis
Hyperthyroid Eye Disease
Cutis Aplasia
Cutis Aplasia Keloid
Cutis Aplasia
Thyroid Binding Globulin (TBG)
Increased TBG
Decreased TBG
Thyroid Regulation
Amiodarone the Thyroid
Amiodarone Effects on Thyroid
Thyroid Hormone
* There is no absorption from the stomach. Absorption occurs in the small bowel.
* The main absorptive sites appear to be the proximal and mid-jejunum.
* Progressively decreasing degrees of absorption occur along the distal bowel and proximal colon.
* Hypothyroidism can lead to a slight increase in absorption.

Thyroid Disease Facts.ppt

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Osteoporosis

Osteoporosis
Capital Conference 2007
By:Marc Childress, MD

Osteoporosis
* Epidemiology
* Risk Factors
* Prevention
* Screening
* Diagnosis
* Treatment
* Osteoporosis in Men
* Management
* Falls
* Acute Complications

Osteoporosis
* Average female bone mineral density peaks at age 35, slow decline thereafter
* Density loss is accelerated post-menopausally

Epidemiology
Risk Factors
Predisposing Medical Conditions
* Estrogen Deficiency
* Inflammatory Bowel Disease
* Type 2 Diabetes Mellitus
* Celiac disease
* Cystic fibrosis
* Hyperthyroidism
* Hyperparathyroidism
* Hypogonadism
* Liver Disease
* Corticosteroid use
* Heparin use
* Cyclosporine use
* Depo-Provera use
* Vitamin A (systemic retinoid) use
* No clear increase in risk with carbonated beverages
* Chronic excess thyroid hormone replacement
* diffuse nontoxic goiter
* osteoarthritis
* osteoporosis
* hyperparathyroidism
* Addison’s disease
* Hypothyroidism
* Osteogenesis imperfecta
* Anticonvulsive medication

Prevention
* Adequate total dietary calcium
* Vitamin D
* Regular weight-bearing exercise
* Additional protective factors: increased BMI, African-American ethnicity, moderate EtOH intake
* Which of the following antihypertensives agents may help preserve bone mineral density?
* Atenolol (Tenormin)
* Doxazosin (Cardura)
* Enalapril (Vasotec)
* Hydrochlorothiazide
* Nifedipine (Procardia, Adalat)
* Which one of the following is associated with a reduced risk of post-menopausal osteoporosis?
* Corticosteroid use
* Cigarette smoking
* Diuretic use
* Low BMI
* Asian Ethnicity
Screening
* USPTF/AAFP— “routine screening” above the age of 65, consider between 60-65 for increased risk
* National Osteoporosis Foundation—recommend screening above 65, or in younger with risk factors
* Difficulty with recommendations
Screening Options
* Single Photon absorptiometry
* Dual Photon absorptiometry
* Dual X-ray absorptiometry (DEXA)—MOST POPULAR
* Quantitative CT
* Ultrasound

Diagnosis
Treatment
* Raloxifene (Evista)
* is used to manage hot flashes
* increases bone density
* stimulates breast tissue
* stimulates endometrial proliferation
* raises LDL and total cholesterol levels

Osteoporosis in Men
Chronic Management
Falls
Acute Complications

Osteoporosis.ppt

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