Describe the sex hormones, hormonal contraceptives and hormone replacement therapy.

Oestrogens and Progestogens

Hormonal Contraceptives

Adverse Effects and Contraindications

• Venous thromboembolism — the most important risk of combined preparations, from the oestrogen; increased several-fold, though the absolute risk in a healthy young woman remains lower than that of pregnancy itself
• Arterial disease — myocardial infarction and stroke, markedly increased in smokers over 35 and with hypertension or migraine with aura
• Other effects — nausea, breast tenderness, headache, mood change, breakthrough bleeding, weight gain, chloasma, raised blood pressure, gallstones
• Cancer — a small increase in breast and cervical cancer risk, against a substantial and lasting reduction in ovarian and endometrial cancer
• Absolute contraindications — pregnancy, previous venous thromboembolism or known thrombophilia, ischaemic heart disease or stroke, migraine with aura, smoking over 35, active liver disease, oestrogen-dependent cancer, and uncontrolled hypertension
• Non-contraceptive benefits — regular lighter periods, less dysmenorrhoea, improvement in acne and in polycystic ovary syndrome, and reduced functional ovarian cysts

Hormone Replacement Therapy

• Indication — troublesome vasomotor symptoms and urogenital atrophy around the menopause, and premature ovarian insufficiency (where it is replacement, not an optional extra)
• A progestogen must be added in a woman with a uterus to prevent endometrial hyperplasia and carcinoma from unopposed oestrogen; oestrogen alone is used only after hysterectomy
• Risks — venous thromboembolism (much lower with transdermal preparations, which avoid first-pass hepatic effects), breast cancer with prolonged combined use, stroke, gallbladder disease
• Benefits — effective symptom relief, and prevention of osteoporotic fracture
• Current position — use the lowest effective dose for symptom control, started near the menopause rather than years later, and review annually; the blanket avoidance that followed early trial reporting is now regarded as having over-corrected, and left many women untreated

Androgens and Antiandrogens

Applied Aspects

• Take a smoking, migraine and thrombosis history before prescribing a combined pill, and measure blood pressure; these three questions prevent most serious harm
• Explain what to do about missed pills and about vomiting or diarrhoea, which is where most real-world failure arises
• Offer emergency contraception without moralising; it is safe, effective and available over the counter in India, and delay reduces its efficacy
• Long-acting reversible methods are far more effective in practice than anything requiring daily action, and should be offered actively rather than only on request
• Female sterilisation still dominates contraception in India, often undertaken young and with limited counselling about reversible alternatives; broadening the method mix is a genuine public health priority
• Vaginal oestrogen is safe and effective for urogenital atrophy even in many women who cannot take systemic hormones, and is greatly under-prescribed
• Tamoxifen requires vigilance for endometrial change — any postmenopausal bleeding in a woman taking it must be investigated, since it is an endometrial agonist
• Finasteride halves the PSA, so the measured value must be doubled when interpreting prostate cancer screening in a man taking it — an easily forgotten point that delays diagnosis
• Anabolic steroid misuse is increasingly common in urban gyms in India, and presents with infertility, gynaecomastia, acne, hypertension and mood disturbance in young men who will not volunteer the history unless asked directly
• Testosterone replacement is not a treatment for ageing, and should follow confirmed biochemical hypogonadism on repeated morning samples rather than symptoms alone
• Check haematocrit and PSA before and during testosterone therapy, since polycythaemia is common and prostate disease may be accelerated
• Clomiphene and letrozole for ovulation induction carry a risk of multiple pregnancy and of ovarian hyperstimulation, and require monitoring rather than unsupervised prescription — which does occur
• Progestogen-only methods are the choice in lactation, in smokers over 35, and wherever oestrogen is contraindicated
• Contraceptive counselling should cover effectiveness in typical use, not perfect use; the gap between the two is what determines real-world pregnancy rates and is why long-acting methods perform so much better
• Depot medroxyprogesterone reduces bone density with prolonged use, which matters most in adolescents who have not reached peak bone mass; the effect largely reverses on stopping
• Do not withhold contraception pending an unnecessary examination; blood pressure and history are what is actually required before a combined pill
• Discuss contraception before starting a teratogenic drug — isotretinoin, valproate, methotrexate, warfarin, ACE inhibitors; this conversation is part of the prescription, not an afterthought