D- GONADAL HORMONES: ESTROGENS AND ANDROGENS

1. D-GONADAL HORMONES:ESTROGENS AND ANDROGENS 1

2. Control of androgen secretion in males (1) competitive inhibition of GnRH receptors (2) stimulation (+, pulsatile administration) or inhibition via desensitization of GnRH receptors (–, continuous administration) Lupron: synthetic analog to GnRH, (3) decreased synthesis of testosterone in the testis (4) decreased synthesis of dihydrotestosterone by inhibition of 5α-reductase (5) competition for binding to cytosol androgen receptors 2

3. Testis Sertoli cells in the testis synthesize and secrete a variety of active proteins, including müllerian duct inhibitory factor, inhibin, and activin. Leydig cells, upon LH stimulation, produced testosterone in the spaces between the seminiferous tubules. As in the ovary, inhibin and activin appear to be the product of three genes that produce a common  α €subunit and two β subunits, A and B. Activin is composed of the two β subunits, stimulates pituitary FSH release Inhibins (A and B), which contain the α subunit and one of the β subunits, in conjunction with testosterone and dihydrotestosterone ,are responsible for the feedback inhibition of pituitary FSH secretion 3

4. Steroid synthesis 4

5. The biosynthetic pathwayof the androgens and estrogens19-carbon precursors are synthesized primarily in the ovaries, testes, and adrenals 5

6. Clinical Uses of Androgens ANDROGEN REPLACEMENT THERAPY IN MEN Androgen production falls with age in men and may contribute to the decline in muscle mass, strength, and libido. USE AS PROTEIN ANABOLIC AGENTS USE AS GROWTH STIMULATORS ANABOLIC STEROID AND ANDROGEN ABUSE IN SPORTS AGING 6

7. ANDROGEN REPLACEMENT replace or augment endogenous androgen secretion in hypogonadal men used rather than gonadotropin except when normal spermatogenesis is desired for hypopituitarism, androgens are not added to the treatment regimen until puberty, started with long-acting agents such as testosterone enanthate or cypionate in doses of 50 mg intramuscularly, initially every 4, then every 3, and finally every 2 weeks, with each change taking place at 3-month intervals. The dose is then doubled to 100 mg every 2 weeks until maturation is complete. Finally, it is changed to the adult replacement dose of 200 mg at 2-week intervals. 7

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9. ANDROGEN SUPPRESSION ANTIANDROGENS Inhibition of Steroid Precursor Conversion to Androgens Ketoconazole-an inhibitor of adrenal and gonadal steroid synthesis Abiraterone- inhibits the 17-hydroxylation of progesterone or pregnenolone to androgens Finasteride,a steroid-like orally active inhibitor of of 5a-reductase that causes a reduction in dihydrotestosterone levels. Moderately effective in reducing prostate size in men with benign prostatic hyperplasia and is approved for this use in the USA. The dosage is 5 mg/d. Dutasteride is a similar orally active steroid derivative with a slow onset of action and a much longer half-life than finasteride. The dose is 0.5 mg daily. Receptor Inhibitors Flutamide- potent anti-androgen that has been used in the treatment of prostatic carcinoma. Although not a steroid, it behaves like a competitive antagonist at the androgen receptor. Cyproterone and cyproterone acetate are effective antiandrogens that inhibit the action of androgens at the target organ Bicalutamide and nilutamide- potent orally active antiandrogens that can be administered as a single daily dose and are used in patients with metastatic carcinoma of the prostate.Spironolactone- a competitive inhibitor of aldosterone that also competes with dihydrotestosterone for the androgenreceptors in target tissues. It also reduces 17-hydroxylase activity, lowering plasma levels of testosterone and androstenedione. It is used in dosages of 50–200 mg/d in the treatment of hirsutism in women and appears to be as effective as finasteride, flutamide, orcyproterone in this condition. GOSSYPOL-abandoned as a candidate male contraceptive. 9

10. ANDROGEN SUPPRESSION

11. Control of ovarian secretion and the actions of its hormones. In the follicular phase, the ovary produces mainly estrogens; In the luteal phase, it produces estrogens and progesterone. SERMs, selective estrogen receptor modulators 11

12. Hormonal relationships of the human menstrual cycle 12

13. Estrogen and Progesterone production and negative feedback

14. Consider the normal menstrual cycle: 1) Estrogen released from the ovary - increases the expression of estrogen receptors. 2) Estrogen increases the expression of progesterone receptors. 3) Progesterone down regulates the expression of estrogen receptors. 4) With the progesterone-elicited decrease in estrogen receptor numbers - there will be a decrease in the ability of estrogen to stimulate the production of progesterone receptors - in this way - progesterone turns itself off. 14

15. Estrogen production from progesterone and testosterone via Aromatase 15

16. Estrogen and synthetic analogs 16

17. Progesterone and synthetic analogs 17

18. Structural Formulas of Selected Estrogens 18

19. Physiological and Pharmacological Actions of Estrogen Developmental Actions: • Puberty and secondary sexual characteristics of females • growth and development of the vagina, uterus, and fallopian tubes • with other hormones cause enlargement of the breasts, promotion of ductal growth, stromal development, and the accretion of fat; molding body contours, shaping the skeleton, and growth spurt of the long bones • growth of axillary and pubic hair and pigmentation of the genital region; regional pigmentation of the nipples and areolae that occur after the first term of pregnancy Metabolic Effects of E: • blocks bone resorption and increases bone formation • increases the level of the hydroxylase that converts vitamin D to 1,25-dihydroxyvitamin D3 in the kidney • slightly elevates serum triglycerides and reduces total serum cholesterol levels • increases HDL levels and decreases LDL values • alters bile composition by increasing cholesterol secretion and decreasing bile acid secretion, leading to increased saturation of bile with cholesterol which may be the basis for increased gallstone formation • decrease slightly fasting levels of glucose and insulin, • increase plasma levels of cortisol-binding globulin (CBG or transcortin), thyroxine-binding globulin (TBG), and sex steroid-binding globulin (SSBG), which binds both androgens and estrogens 19

20. Alters liver metabolism Affects on clotting and fibrinolysis - ↑ fibrinogen levels - ↑ synthesis of clotting factors (VII, IX, X, XIII) - ↑ plasminogen levels - ↓ plasminogen activator inhibitor Alters metabolism of lipoproteins - ↑ HDL - ↑ TG - ↓ LDL - ↓ total cholesterol Other - increases angiotensinogen and transport proteins Physiological Effects of Estrogen 20

21. Physiological Effects of Estrogen Alters vascular reactivity (endothelial mediators of contraction and relaxation) - ↓ endothelin-1 - ↓ TXA2 receptors - ↓ angiotensin II receptors - ↓ superoxide free radicals - ↑ nitric oxide synthase expression and activity therefore ↑ nitric oxide 21

22. Estrogen Receptor Isoforms 22

23. Estrogen Receptor Signaling 23

24. Mechanisms of Steroid Hormone Signaling 24

25. AP-1 Sp1 25

26. Elimination of Estrogens 17β-estradiol is primarily converted by 17β-hydroxysteroid dehydrogenase to estrone, and converted by 16α-hydroxylation and 17-keto reduction to estriol, which is the major urinary metabolite; sulfate and glucuronide conjugates also are excreted in the urine. Estrone also is converted to the catechol estrogen, or 2-hydroxyestrone which is methylated to 2-methoxyestrone 26

27. Therapeutic Uses of E2: • pharmacological considerations for E use in OC and HRT are different because of the dose • conjugated estrogens for HRT (0.625 mg/day for most women; 1.25 mg in some patients) • combination oral contraceptives in current use employ 20 to 35 mg/day of ethinyl estradiol • Conjugated estrogens and ethinyl estradiol differ widely in their oral potencies; for example, a dose of 0.625 mg of conjugated estrogens generally is considered equivalent to 5 to 10 mg of ethinyl estradiol 27

28. Physiological and Pharmacological Actions of Progesterone: Neuroendocrine Actions: • P decreases the frequency of the hypothalamic pulse generator and increases the amplitude of LH pulses Reproductive Tract: • P released during the luteal phase of the cycle decreases estrogen-driven endometrial proliferation and leads to the development of a secretory endometrium • decline in P release from the corpus luteum at the end of the cycle determines onset of menstruation • P influences the endocervical glands; the abundant watery secretion of the estrogen-stimulated structures is changed to a scant, viscis material, decreasing penetration of the cervix by sperm • E-induced maturation of the vaginal epithelium is modified toward the condition of pregnancy by P • P is very important for the maintenance of pregnancy: suppress menstruation and uterine contractility, which led to the use of progestins to prevent threatened abortion. However, such treatment is of questionable benefit because diminished P is rarely the cause of spontaneous abortion Mammary Gland: • P, acting with E, induces proliferation of the acini of the mammary gland • during the normal menstrual cycle, the mitotic activity in the breast epithelium is very low in the follicular phase and then peaks in the luteal phase… P triggers a single round of mitotic activity • in contrast, in the endometrium, proliferation is greatest in the follicular phase due to increasing E and is opposed by P in the second half of the cycle • hormonal control of proliferation is thus different in breast and endometrium; these cell-specific effects should be kept in mind when interpreting therapeutic and untoward effects of E and P 28

29. Physiological and Pharmacological Actions of Progesterone: CNS Effects: • an increase of about 1°F may be noted midway through the normal menstrual cycle at the time of ovulation • the temperature rise persists for the remainder of the cycle until the onset of the menstrual, and thus clearly due to P. The mechanism of this effect is unknown • P increases the ventilatory response of the respiratory centers to carbon dioxide and leads to reduced arterial and alveolar PCO2 in the luteal phase of the menstrual cycle and during pregnancy • P may have depressant and hypnotic actions, perhaps inducing drowsiness after administration Metabolic Effects: • P increases basal insulin levels and the rise in insulin after carbohydrate ingestion • long-term administration of more potent progestins, such as norgestrel, may decrease glucose tolerance • P stimulates lipoprotein lipase activity and seems to enhance fat deposition • P and medroxyprogesterone acetate (MPA) cause either no effect or modest reduction in serum HDL; 19-nor progestins may cause more pronounced decrease in HDL levels, possibly due to androgenic activity. Thus, progestins may diminish the beneficial effects of estrogens on serum lipoprotein profiles in situations where the two agents are given together, such as OCs and HRT. • P may diminish the effects of aldosterone in the renal tubule and cause a decrease in sodium reabsorption that may increase mineralocorticoid secretion from the adrenal cortex 29

30. Progesterone Receptor • Progestins are lipophilic and diffuse freely into cells where they bind to the PR (PR-A and PR-B) • PRs are ligand-activated nuclear transcription factors that interact with a progesterone response element in target genes to regulate their expression • PRs are expressed in the female reproductive tract, the mammary gland, the CNS (including the pulse generator in the hypothalamus), and the pituitary • expression of PRs is induced by estrogens; its presence is a common marker for E action • A single PR gene yields two forms of the receptor, the so-called A and B forms that arise from two translational start codons; the physiological and pharmacological significance of the two forms is unknown, but may relate to intracellular vs cell surface membrane PR • progestins enhance differentiation and oppose the actions of E to stimulate cell proliferation by decreasing ER levels, increasing local metabolism of estrogens to less active metabolites, or induction of gene products that blunt cellular responses to estrogenic agents 30

31. Progesterone derivatives 31

32. Biological Activity of Progestins 32

33. Relationship Between Estrogen and Progesterone 1) Estrogen exerts positive feedback on its own activity. Estrogen stimulates the expression of estrogen receptors. 2) Estrogen must precede progesterone to elicit full progesterone sensitivity. Estrogen stimulates the expression of progesterone receptors. 3) Progesterone has anti-estrogenic activity - which helps to terminate estrogenic activity. - Progesterone suppresses expression of estrogen receptors. - Progesterone facilitates the metabolism of estradiol to weaker metabolites. - Progesterone may act as a partial agonist at the estrogen receptor. 33

34. Hormone Replacement Therapyand Fertility Drugs Menopause: cessation of menses; loss of ovarian function leading to a state of permanent amenorrhea Ovarian follicle no longer responds to gonadotropin, thus estrogen is not produced Lack of negative feedback results in increased levels of gonadotropins (FSH and LH) Amenorrhea lasting 1 year – average age 51.4 years (2 yrs earlier in smokers) Climacteric: series of physiologic, endocrinologic and psychologic changes that signify the transition from reproductive to non-reproductive life that spans several years – perimenopausal 34

35. Menopause TimetableWomen may enter menopause earlier than they realize. Estrogen levels usually drop before menopausal symptoms are seen. Below, the typical ages for various symptoms. SYMPTOM AGE -35 40 45 50 55 60 65 70 Dropping estrogen levels Menstrual irregularity Mood swings Loss of concentration Hot flashes Vaginal dryness Last period Osteoporosis Heart Disease Sources: “Perimenopause: Preparing for the Change” by Nancy Lee Teaff and Kim Wright (Prima Publishing, 1996); “Perimenopause: Changes in Women’s Health After 35” by Drs. James E. Huston and L. Darlene Lanka (New Harbinger, 1997). 35

36. Menopause • Vasomotor instability (hot flashes), night sweats • Increase incidence of cardiovascular disease • Osteoporosis • Genitourinary atrophy • Metabolic changes – fat redistribution • Skin changes • Insomnia, fatigue, dysphoria, anxiety • Loss of memory?, susceptibility to dementia? 36

37. Proposed Benefits of HRT • Cardiovascular • Decreased incidence of cardiovascular disease • Improved lipid profiles • Vasodilatory effects • Antiplatelet activity • Decreased fibrinogen levels • Direct myocardial effects • Antioxidant activity • Non-Cardiovascuclar • Prevention of bone loss* • Treatment of vasomotor symptoms (hot flashes)* • Prevention of colon cancer • Prevention of Alzheimer’s disease • Prevention of urinary incontinence • Alleviation of sleep disorders * known effects of estrogen 37

38. Routes and Compounds • Oral Estrogens • Premarin, Cenestin • Esterified estrogen • Ethinyl estradiol • Estrone sulfate • Micronized estrogen • Transdermal Estrogens • Less effects on liver – no first pass effect • Patches, creams • Vaginal Estrogens • Vaginal creams – including premarin • Vaginal ring • Parenteral Estrogens • Estrogen esters • Progesterones • Medroxyprogesterone acetate • Norethindrone – etc. • Micronized progesterone 38

39. Examples of HRT Preparations • Prempro – continuous combined Premarin and Provera Premphase - continuous sequential Premarin 14 days then Premarin plus Provera for next 14 days • FEMHRT – continuous combined ethinyl estradiol plus norethindrone • Ortho-Prefest – continuous combined; 6 day cycle – day 1-3 micronized estradiol and day 4-6 micronized estradiol with norgestimate 39

40. Relative Risk for Estrogen Use and Coronary Heart Disease Study Type Pop Case-Control Hospital Case-Control Prospective Internal Control Cross-Sectional Prospective External Control All Studies Combined Prospective Internal Control and Cross Sectional 2 0 1.5 1 RR 0.5 40